This form is for privacy-related requests only. To report Adverse Events or Product Complaints, contact Ipsen Biopharmaceuticals, Inc. at 1-855-463-5127. Adverse reactions may also be reported to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.


Directions: Please provide the information requested below to the best of your ability. If you already receive any correspondence from Ipsen, provide your information as it appears on the materials you receive from us. We will respond to your request as required by applicable state law. Depending on the nature of your request, we may need to contact you for additional information for verification purposes. Please note that email address is required so that we can provide final confirmation on how your request was handled. Personal Information provided on this form will only be used to process your request. For additional information regarding privacy at Ipsen please visit www.ipsen.com/us/privacy-policy/.

Myself
On behalf of someone else
Access Data
Correct Data
Delete Data
Opt-out of “Sale”/Online Targeted Advertising
Limit Use and Disclosure of Sensitive Personal Information
Revoke Prior Consent/Authorization
Appeal Ipsen Response to Prior Individual Rights Request
Patient/Consumer
Caregiver
HCP
Ipsen Employee
Other
Enter the first name of the data subject.
Enter the last name of the data subject.
Enter email for correspondence with the data requester.
Enter country of residence.