NovoPen® Echo® Request Form

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This form enables Canadian Pharmacy Healthcare Professionals to request NovoPen® Echo® devices from Novo Nordisk Canada Inc.


This form is to be used to submit NovoPen® Echo® device requests to Novo Nordisk Canada Inc. and does not constitute an order. All order fulfilment is at the discretion of Novo Nordisk Canada Inc.


Once received at the pharmacy, NovoPen® Echo® devices are to be distributed to the patients who have requested them at no cost. NovoPen® Echo® devices are NOT FOR RESALE.


This program may change or end at at the discretion of Novo Nordisk.


Please direct any questions to:


Novo Nordisk Canada Inc.

101-2476 Argentia Road

Mississauga, Ontario L5N 6M1

Phone: +1 905 629 4222

Phone (Toll-free): +1 800 465 4334

Fax: +1 905 629 8662

Fax (Toll-free): +1 844 465 2225

www.novonordisk.ca


IMPORTANT: This form is to be completed by Pharmacy Healthcare Professionals only.


Contact Information

Select
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Phone

This email address MUST belong to the Pharmacist requesting the NovoPen® Echo® devices.


Please be advised that this is a request only and does not guarantee that this number of NovoPen® Echo® devices will be provisioned.

Select
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NovoPen® Echo® Colour Preference - Pen 1*
NovoPen® Echo® Colour Preference - Pen 2*

Confirmation of Use


Consent for Electronic Messages

Novo Nordisk Canada Inc. will not use your personal data for purposes other than to communicate about this request for NovoPen® Echo® devices. Your data will not be sold, rented, leased or given away to any third party.


You may withdraw your consent at any time. Refer to Novo Nordisk Canada Inc.'s privacy policy or contact us if you have any questions.