Massachusetts HCP Opt-Out of Sunovion Communications Form

As required by the Commonwealth of Massachusetts' Pharmaceutical and Medical Device Manufacturer Code of Conduct regulations, Sunovion Pharmaceuticals Inc. is providing health care practitioners the opportunity to request that their prescriber data be withheld from Sunovion Sales Representatives and/or not be used by Sunovion for marketing purposes. If you would like Sunovion to restrict the use of your prescriber information, please enter your contact information and select either one or both restrictions.

If you are a Health Care Provider and a member of the American Medical Association (AMA), you can elect to have your data withheld from all pharmaceutical representatives by visiting https://www.ama-assn.org/physician-data-privacy.

If you would prefer to have your information withheld from Sunovion pharmaceutical representatives and/or not be used by Sunovion for marketing purposes, please enter your information below.

First Name* :

Last Name* :

Address* :

City* :

State* :

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code* :

Phone Number* :

MA State License #* :

*required

Withhold my prescribing data from Company Sales Representatives

Not use my prescribing data for marketing purposes

By clicking on the Submit button below, I certify that I am a Health Care Practitioner licensed by Massachusetts and that Sunovion Pharmaceuticals Inc. shall (please check all relevant boxes):

Submit