Thank you for sharing your recent experiences regarding the EpiPen® shortage with us. Your information will be kept confidential and will only be used to help inform us, so we can continue to advocate on this issue.

If you have any questions, please contact us at info@foodallergycanada.ca.

Tell us about yourself:

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* 1. Tell us about yourself:

Where are you from?

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* 2. Where are you from?

How have you been impacted by the EpiPen shortage?

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* 3. How have you been impacted by the EpiPen shortage?

Have you been able to fill your prescription?

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* 4. Have you been able to fill your prescription?

How many pharmacies have you visited to fill your prescription?

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* 5. How many pharmacies have you visited to fill your prescription?

Which pharmacies did you visit?

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* 6. Which pharmacies did you visit?

What did the pharmacies tell you about the shortage?

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* 7. What did the pharmacies tell you about the shortage?

Select all the reasons you need new EpiPen(s):

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* 8. Select all the reasons you need new EpiPen(s):

Have you contacted Pfizer Canada to let them know how you have been impacted?

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* 9. Have you contacted Pfizer Canada to let them know how you have been impacted?

How do you pay for your EpiPen? Select all that apply.

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* 10. How do you pay for your EpiPen? Select all that apply.

Would you like to share your story if media wants to speak to families impacted by this shortage?

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* 11. Would you like to share your story if media wants to speak to families impacted by this shortage?

Please share anything else you would like us to know about this issue.

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* 12. Please share anything else you would like us to know about this issue.

Thank you for sharing your experiences with us. We will be in touch soon with an update on this issue.

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