IUD Replacement Request

This site is intended for US Healthcare Professionals Only.

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*

Attempted Insertion Date:

Description of Incident*

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