Welcome to the High Cost Drugs Requests Portal

Please note, an asterisk next to a question means that this requires an answer

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* 1. Please enter today's date

Date

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* 2. Please tell us your name

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* 3. Please tell us the organisation that you represent

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* 4. To ensure we can update you with regard to the request, please tell us your e-mail address

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* 5. In case we need to contact you by phone, please tell us your telephone number (this field is not mandatory)

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* 6. Please select the role that you have in your organisation

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* 7. Please select one of the following options:

T