Nationwide and Regional Cancer Care Report, 2011-2012 Edition: Order Form

To receive the 2011-2012 Cancer Care Report, please provide the information requested below.

By providing the information below you are giving Kikaku America International (the publisher of the Nationwide and Regional Cancer Care Report, 2011-2012 Edition), and sanofi-aventis (the report sponsor), permission to contact you about this publication or their products. If you do not want to be contacted by either party, please answer "No" to question 4 below.

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Once you have entered all the information requested below, please continue to the second page of this form and click the "Done" button to complete your order.

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1. Please provide the following information about yourself (required):

Name: *

Company: *

Address: *

Address 2:

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State: *

ZIP/Postal Code: *

Email Address: *

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2. What type of organization do you work for?

Private Practice

Managed Care Organization

PBM/Specialty Pharmacy/Mail Service Pharmacy

Pharmaceutical Manufacturer

Other (please specify)

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3. You are:

Practicing Physician

Administrator

Sales

Managed Care

Medical Director

Pharmacy Director

Nurse

Pharmacist

Other (please specify)

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4. May we contact you about other valuable information?

Yes

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5. Please specify which regional report(s) you would like to receive:

Northeast US

Southeast US

Central US

Southwest US

West US

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6. How interested are you in seeing the following oncology topics addressed in future free issue brief publications?

	Very Interested	Somewhat Interested	Not Interested
Drug shortages	Drug shortages Very Interested	Drug shortages Somewhat Interested	Drug shortages Not Interested
Patient benefit structure	Patient benefit structure Very Interested	Patient benefit structure Somewhat Interested	Patient benefit structure Not Interested
Guidelines for oncology care (non-NCCN Guidelines^®)	Guidelines for oncology care (non-NCCN Guidelines^®) Very Interested	Guidelines for oncology care (non-NCCN Guidelines^®) Somewhat Interested	Guidelines for oncology care (non-NCCN Guidelines^®) Not Interested
Guidelines for oncology care (NCCN Guidelines^®)	Guidelines for oncology care (NCCN Guidelines^®) Very Interested	Guidelines for oncology care (NCCN Guidelines^®) Somewhat Interested	Guidelines for oncology care (NCCN Guidelines^®) Not Interested
The role of Specialty Pharmacy	The role of Specialty Pharmacy Very Interested	The role of Specialty Pharmacy Somewhat Interested	The role of Specialty Pharmacy Not Interested
Medical Benefit vs. Pharmacy Benefit	Medical Benefit vs. Pharmacy Benefit Very Interested	Medical Benefit vs. Pharmacy Benefit Somewhat Interested	Medical Benefit vs. Pharmacy Benefit Not Interested
NCCN Compendium^®	NCCN Compendium^® Very Interested	NCCN Compendium^® Somewhat Interested	NCCN Compendium^® Not Interested
Personalized Medicine	Personalized Medicine Very Interested	Personalized Medicine Somewhat Interested	Personalized Medicine Not Interested
Clinical pathways (physician-generated)	Clinical pathways (physician-generated) Very Interested	Clinical pathways (physician-generated) Somewhat Interested	Clinical pathways (physician-generated) Not Interested
Management of oral drugs	Management of oral drugs Very Interested	Management of oral drugs Somewhat Interested	Management of oral drugs Not Interested
End of life management	End of life management Very Interested	End of life management Somewhat Interested	End of life management Not Interested
Parity legislation	Parity legislation Very Interested	Parity legislation Somewhat Interested	Parity legislation Not Interested
Clinical pathways (external vendor-generated)	Clinical pathways (external vendor-generated) Very Interested	Clinical pathways (external vendor-generated) Somewhat Interested	Clinical pathways (external vendor-generated) Not Interested

Other (please specify topics and level of interest for each)

Question Title

7. Are there any compliance or adherence topics you believe should be addressed in future publications? If so, please specify them below:

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