• Zentir Medirequests

    Interactive Forms with
    Signature Auditing Capabilities

  • Starter Pack Request Form


    Drug X is indicated for the treatment of Lorem Ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod. Lorem Ipsum dolor sit amet.

    Reason(s) for Start Pack Request:
    (please select relevant box)

    For immediate use in surgery for relief of symptoms

    For use of alternate treatments, prior to prescription being written

    For gaining familiarisation with products

    For after hours use

    Number of Starter Packs required:

    Preffered method of delivery:

  • Publication Request Form

    Primary Publication:

    Primary Publication

    Freemantle et al.
    Publication Bias in Clinical Trials and
    Economic Analysis
    Pharamcoeconomics 1997 Jul 12 (1) 10-16

    Clinical Publications:

    Publication A (Freemantle et al)

    Publication B

    Publication C

    Publication D

    Preffered method of delivery:

  • Patient Materials Request Form

    Patient support program

    Patient Support Program

    Number of Starter Packs required:

    Preffered method of delivery:

  • Medirequests

    I confirm that I am a registered Australian healthcare professional.


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    The details you have provided for the specific purpose of this request will not be disclosed to anyone other than the authorised third parties who provide the service in order to fulfil this request, or unless compelled or permitted by law to do so.
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