Drug Information Request Form Heading link Copy link Name:(Required) First Last Medical provider type:(Required)PhysicianNurse PractitionerPAOtherNational Provider Identification (NPI) number: Practice site name:Prescriber/Provider Site (eg, UIC) Practice site zip code: Phone number: Email:(Required) Enter Email Confirm Email Question:(Required)Additional information you would like us to know to respond to your request:How would you like to receive a response?(Required)PhoneEmailIf you would like to receive a phone response, what is the best time to call?