Inquiry Form

"*" indicates required fields

HCP Contact Information

HCP Name*

Site Information

Site Address*

Alternate Contact Information

Alternate Contact Name
Does your site have Radio Ligand experience?*
Does your site have an Adequate Radioactive Materials License (receipt/handling/possession limit [Lu-177])?*
Does your site have an Authorized User Physician who is approved to administer Radioactive Materials?*
Can your site use a Central IRB?*

Patient Related Information

Does the patient(s) have a serious or immediately life-threatening illness?*
Is the patient(s) eligible for, or have access to any ongoing clinical trials?*
Is there a satisfactory or comparable alternative therapy available?*
MM slash DD slash YYYY

You will receive an acknowledgement of this request within five (5) business days after receipt.