Climara Replacement

Climara & Climara Pro Replacement Request

To submit a Climara or Climara Pro Replacement Request to Bayer Medical Information, a pharmacy must complete the required fields below. Please submit one product replacement request per form. This form is not meant to be used for the reporting of adverse events. To report an adverse event, please use our online AE reporting portal

*Indicates required fields

Product Information

Product Name for Replacement*

Dosage

Quantity of Patches Needing Replacement*

Pharmacy Contact Information

Pharmacy Name*

Pharmacy Address*

Pharmacy City*

Pharmacy State*

Pharmacy Zip*

Pharmacy Phone*

Pharmacy’s State License No.*

Pharmacist’s Name*

Email*

Rx Number*

Reason for Replacement*

By clicking the submit button I confirm that this is an unsolicited request.

Climara Webform

Climara & Climara Pro Replacement Request

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