Medical Information Request

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Medical Information Request

For requests from Healthcare Professionals

Title

First Name

Last Name

Speciality

If other, please specify

Practice Name

Address

Suburb

State

Post code

Phone

Email

Inquiry details

Preferred communication method:

Mail

Fax

Email

In-person meeting with a Medical Affairs representative

Phone discussion with a Medical Affairs representative

Healthcare Professional Confirmation(Required)

I confirm I am a healthcare professional registered to practice in Australia and I request the above information to be provided to me by a company representative or their designated agent.

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To streamline the process of placing all INOmax orders, we encourage healthcare professionals to register and login. This enables tracking of orders for your account and will simplify order placement.

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Therakos Australia Pty Ltd, Hawthorn, Victoria 3122. Tel: 1800 945 225. ABN 91 680 863 138.
Therakos, the circle brand mark and the Therakos logo are trademarks of a Therakos company. Other brands are trademarks of a Therakos Company or their respective owners.
^© 2025 Therakos Australia Pty Ltd.

Date of preparation: July 2025. AU-2500013 v1.1

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