Medical Information Request Form This resource is intended for US-based medical and scientific professionals only. Preferred ResponseEmailFaxMailName* First Last Zip Code*Professional DesignationSelect oneMDPhysician AssistantPharmacistNursePhDOtherInstitutionAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Email* Enter Email Confirm Email Email Enter Email Confirm Email PhoneFaxFax*Medical Information Request*Please note that any requests for published literature or journal reprints may fall under the physician payment reporting provisions of Patient Protection and Affordable Care Act of 2010 (the “Sunshine Provisions”) or other applicable state laws. These provisions require that all applicable manufacturers, including Flexion Therapeutics Inc., track and report to the Centers for Medicare and Medicaid Services (CMS) or applicable state agency, all transfers of value to U.S. Physicians, specifically including the value of journal reprints.CAPTCHATimeIMPORTANT NOTICE – This information is intended for US-based medical and scientific professionals only.*I confirm I am a US-based medical and scientific professionalI am not a US-based medical and scientific professionalNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.