Medical Information Request Form

A. Healthcare Professional Contact Information:

Full Name:

Mailing Address:

State:

Telephone Number (including area code):

Email:

Degree:

City:

Zip Code:

Fax Number:

Preferred Method of Response:

Phone Mail Email Fax

Products:

Inquiry:

To report an Adverse Event please contact Elan at 1-877-352-6477

For medical information regarding Azactam (aztreonam), please contact Bristol-Myers Squibb at www.bms.com

For medical information regarding Prialt^® (ziconotide intrathecal infusion), please contact Azur Pharma at www.azurpharma.com