Alosetron REMS

1. Review the Alosetron REMS Prescriber Education Slide Deck:

2. Fill out the Prescriber Completion of Alosetron REMS Program Training Form

Individual NPI Number*

NPI

Office Name

First Name*

Last Name*

Specialty*

Specialty - Other*

Office Address Line 1*

Office Address Line 2

Office City*

State*

Zip Code*

Office Phone*

Ext.

Office Fax*

Email*

Preferred Method of Contact*

Email
Fax

3. Sign and Submit the form to complete your training*

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Prescriber