Cordis Corporation Medical Information Request Form

Healthcare professionals must submit a completed Medical Information Request Form to allow use of personal information by Cordis. (This form does not apply to anyone other than healthcare professionals.)

Cardiology

Call Center Number: 1-800-781-0282
Fax Number: 908-927-5786

Endovascular

Call Center Number: 1-877-338-4235
Fax Number: 908-927-5133

Gastroenterology (biliary stents and related products)

Call Center Number: 1-877-338-4235
Fax Number: 908-927-5133

I certify that I am a licensed medical professional within the United States: *

I certify that I am a licensed medical professional within the United States. (This box must be checked in order to proceed)

By checking this box and submitting your personal information, you agree that Cordis Corporation and companies that work with Cordis Corporation, can use your information to fulfill this request. Your information will be kept in accordance with our Privacy Policy.

CONTACT INFO: (Please complete the entire form.)

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Phone: *

Fax:

Email: *

Confirm Email: *

Title: *

Company/Institution: *

Specialty/Practice: *

Degree: *

REQUEST: (Please be as specific as possible. Requested information will be delivered within 48 hours.)

Topic(s): *

Author(s)/ Presenter(s): *

Congress: *

Patient Group: *

Lesion Type: *

Slide Request:

Slide Request

Medical Letter/ Medical Information Request:

Medical Letter/ Medical Information Request

Request: *

IF AN ADVERSE EVENT AND/OR PRODUCT COMPLAINT WAS ASSOCIATED WITH THIS REQUEST, IMMEDIATELY CONTACT THE CORDIS CORPORATION PRODUCT QUALITY DEPARTMENT AT 1-800-327-7714 TO REPORT THE EVENT OR COMPLAINT.