IUD Replacement Request

To submit an IUD Replacement Request to Bayer Medical Information, please complete the required fields below.

Please submit one product replacement request per form.

*Indicates required fields

Physician Contact Information

Healthcare provider who inserted the IUD*

Healthcare Facility where Incident Occurred*

Reporter name (if different)

Reporter phone number (if different)

Address*

City*

State*

Zip Code*

Phone*

E-mail*

Product Information

Product Name for Replacement*

Formulation

Strength

Lot Number*

Unit Available for Return?*

Yes

Please select why sample is unavailable

Do you need to report any Adverse Event(s) related to this Replacement Request?*

Yes

Adverse Event Reference Number*

Description of Incident*

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