Mayne Pharma - Samples Order Form

Number of NEXTSTELLIS samples requested (one month supply)*

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I would like NEXTSTELLIS patient education materials

I would like to be contacted by a Mayne Pharma representative for further information on NEXTSTELLIS (E4/DRSP).

I would like an independent clinical review paper on NEXTSTELLIS.

Name*

First NameLast Name

Email

example@example.com

Clinic name*

Address

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I am a registered Australian healthcare professional that is able to prescribe prescription products.

By completing this sample request form, I consent to Mayne Pharma contacting me. My information will not be shared with a third party and I can opt out at any time by contacting au.enquiries@maynepharma.com.

Mayne Pharma complies with the Privacy Act 1988. Details of our privacy policy can be found at maynepharma.com/privacy-policy.

PBS Information: This product is not listed on the PBS.

Please review the Full Product Information before prescribing.
Full Product Information is available from nextstellis.com.au

NEXTSTELLIS is a registered trademark used under license. Mayne Pharma International Pty Ltd, ABN 88 007 870 984. 1538 Main North Road, Salisbury South, SA 5106. Telephone: 1300 081 849. NEX0014b. Date of preparation: May 2022.

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