REQUESTS FOR INITIATION DOSES OF ARAVA ® (leflunomide)
PLEASE PRINT THIS PAGE, SIGN, AND FAX TO 888-660-1355
Arava: Initiation Dose Request
Manufacturer: sanofi-aventis U.S. LLC, Bridgewater, NJ ,08807
Authorized Distributor of Record: PROMOTECH Logistics Solutions LLC

Your request will contain the following:
5 patient-initiation doses of Arava® (leflunomide) [each containing 3 X 100-mg tablets]
 
 
(Please check one)
MD
DO
Other (specify): 
 
Practitioner's Name:  
 
Street Address:  
 
City:       State:         Zip: 
 
Phone Number:        Date of Request: 
        (Enter 10 digit no.)
 
State License Number:
  (Required for initiation dose requests)
I certify that I am the individual identified above, licensed and authorized to prescribe and receive samples of the prescription product requested above to treat the medical needs of my patients. I understand that this is a prescription product sample and agree not to offer or sell, trade, barter, or seek reimbursement for these samples.
 
Signature (required) :
  (Actual signature required, no stamps please)
 

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E-mail Address: 
 
 
Please see full prescribing information, including boxed warning regarding use in pregnancy.
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US.LEF.12.08.001
Last Update: April 2012