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Patient enrolment

By completing and submitting this form, you agree to be enrolled in the Ipsen Assist Somatuline^® Autogel^® (lanreotide) Patient Support Program. For assistance with completing this form, please call 1800 477 366 to speak to the Ipsen Assist team.

\n","NextButtonLabel":"NEXT - FURTHER INFORMATION ","Type":"BookingService","Children":[{"ID":891,"Name":"patient-details","SortOrder":-10,"Title":"PATIENT DETAILS","Type":"FormFieldSet","Children":[{"ID":892,"Name":"892","SortOrder":-10,"Title":"FirstName","ColumnWidth":4,"HideLabel":false,"DataField":"FirstName","Type":"FormFieldPart","Children":[]},{"ID":893,"Name":"893","SortOrder":-5,"Title":"LastName","ColumnWidth":4,"DataField":"LastName","Type":"FormFieldPart","Children":[]},{"ID":894,"Name":"894","SortOrder":-2,"Title":"DateOfBirth","ColumnWidth":4,"DataField":"DateOfBirth","Type":"FormFieldPart","Children":[]},{"ID":895,"Name":"895","SortOrder":0,"Title":"MobilePhone","ColumnWidth":4,"HideLabel":false,"AltLabel":"Contact Telephone Number","DataField":"MobilePhone","Type":"FormFieldPart","Children":[]},{"ID":896,"Name":"896","SortOrder":10,"Title":"Email","DataField":"Email","ColumnWidth":4,"Type":"FormFieldPart","Children":[]},{"ID":897,"Name":"897","SortOrder":20,"Title":"Postcode","DataField":"Postcode","ColumnWidth":4,"Type":"FormFieldPart","Children":[]},{"ID":910,"Name":"910","SortOrder":30,"Title":"DipherelineConfirmation","DataField":"DipherelineConfirmation","RequiredMessage":"Confirmation is required.","Type":"FormFieldPart","Children":[]}]},{"ID":898,"Name":"further-information","SortOrder":0,"Title":"FURTHER INFORMATION","Type":"FormFieldSet","Children":[{"ID":899,"Name":"899","SortOrder":-10,"Title":"ExerciseServiceMode","DataField":"ExerciseServiceMode","Type":"FormFieldPart","Children":[]},{"ID":900,"Name":"900","SortOrder":-5,"Title":"EPList","DataField":"EPList","Type":"FormFieldPart","Children":[]},{"ID":901,"Name":"901","SortOrder":-2,"Title":null,"Content":"

So we can contact your doctor about your participation in the program, please provide the full name of the doctor that prescribed Diphereline^® for you

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Terms and Conditions |Privacy Policy

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Welcome to Ipsen Assist.

Ipsen Assist is a support program designed to assist in the management of patients prescribed an Ipsen product for approved indications.

To enrol a patient in the program please enter the access code in the field below:

If you do not have an access code call Ipsen Assist on 1800 477 366.

Welcome to Ipsen Assist.

Ipsen Assist is a support program designed to assist patients using Ipsen products for approved indications.

To enrol in the program, please enter the access code in the field below:

If you do not have an access code call Ipsen Assist on 1800 477 366.

Welcome to Ipsen Assist.

Ipsen Assist is a support program designed to support patients using an Ipsen medication.

If you would like more information about the program speak to your doctor.