Authorization

Create an AstraZeneca Account

{* #registrationForm *}

Enter your personal details

{* firstName *} {* lastName *} {* npiNumber *}

Enter your account details

{* emailAddress *}

{* newPassword *}

{* newPasswordConfirm *}

You confirm that by registering on this site, you authorize AstraZeneca and its service providers to hold the personal information that you supply for the purposes of providing access to this website. This will include validation that you are a healthcare professional. AstraZeneca respects your personal information. AstraZeneca and its service providers will not sell or rent your personal information. Your data will be safeguarded in accordance with AstraZeneca’s global privacy and information security policies. Further information on how AstraZeneca processes your personal data can be found in the AstraZeneca Privacy Notice (www.azprivacynotice.com). If you have any questions please email privacy@astrazeneca.com

I certify that I am a practitioner who can legally prescribe in my state. If I am a practitioner with dependent authority in my state, I certify that I have a current Collaborative Agreement on file with my collaborating physician which includes the samples requested. I am requesting product samples from AstraZeneca so that I may have an opportunity evaluate the tolerability and effectiveness of AstraZeneca products in an appropriate patient. I will not sell of offer to sell, trade or barter these samples nor will I seek reimbursement from any payer for providing these samples to a patient. I further certify that I will provide my personal signature for each order request and that it is legally binding.

{* generalConsent *}

{* backButton *}

{* /registrationForm *}

{* mergeAccounts {"custom": true} *}

{| rendered_current_photo |}

{| current_displayName |}
{| current_emailAddress |}

{| foundExistingAccountText |} {| current_emailAddress |}.

{| moreInfoHoverText |}
{| existing_displayName |} - {| existing_provider |} : {| existing_siteName |} {| existing_createdDate |}

{| moreInfoText |}

{| rendered_existing_provider_photo |}

{| existing_displayName |}
{| existing_provider_emailAddress |}

Created {| existing_createdDate |}

{| connectLegacyRadioText |}

{| createRadioText |} {| current_provider |}

Validating

{| connect_button |} {| create_button |}

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