Inquiry Form - Lantheus

HCP Name*

HCP Telephone*

HCP Email*

Site Name*

Site Address*

Alternate Contact Name

Alternate Telephone

Alternate Email

Does your site have Radio Ligand experience?*

Yes

No

Does your site have an Adequate Radioactive Materials License (receipt/handling/possession limit [Lu-177])?*

Yes

No

Does your site have an Authorized User Physician who is approved to administer Radioactive Materials?*

Yes

No

Can your site use a Central IRB?*

Yes

No

Does the patient(s) have a serious or immediately life-threatening illness?*

Yes

No

Is the patient(s) eligible for, or have access to any ongoing clinical trials?*

Yes

No

Is there a satisfactory or comparable alternative therapy available?*

Yes

No

HCP Signature*

Date*