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mentor request form

SIGN UP TO SPEAK WITH A MENTOR

Fill out this short form to connect with one of our DUPIXENT MyWay® Mentors.

Tell us about yourself

We just need you to answer a few questions to verify your eligibility and contact information.

Note: All information is required unless otherwise indicated.

Your Birthdate
Age Range of Patient:

Patient must weigh at least 33 lb (15 kg)

Find a mentor

Fill out the questions below to help us find the best Mentor for you.

Note: All information is required unless otherwise indicated.

Do you have a DUPIXENT prescription?
Discussion Topics (Choose All That Apply):
Language Preference:

Communication Preferences

Fill out the questions below to set up the best time to meet with a Mentor.

Note: All information is required unless otherwise indicated.

Which Day(s) Work Best for Calls? (Select All That Apply):
Which Times Work Best for Calls? (Select up to 3):
Select Your Time Zone
Select
How Did You Hear About the Program?
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Additional Communication Preferences:

I acknowledge that by checking the checkbox, I consent to receive text messages from Sanofi regarding DUPIXENT at the mobile telephone number that I provide. Message and data rates may apply. I understand that I can opt out at any time by texting STOP and I can get help by texting HELP to 94742. Message frequency will vary. I understand that my consent is not required as a condition of purchasing any goods or services.

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You may have certain rights under applicable data privacy laws regarding the personal information that you provide to Sanofi, including the right to access your personal information held by Sanofi. For further information regarding these rights, please reference our Global Privacy Policy.