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Medical Information Request

To ensure a prompt response, please fully complete this form

(* indicates a required field)

Your question or information request *  

 
 
Send information via: *  
  Email        Fax        Mail
 

Your Personal Information

 
First Name *  
 
Last Name *  
 
Address *  
 
Address (suite, apt, etc.)  
 
City *  
 
State *  
 
Zip / Postal Code *  
 
Phone * 
 
Fax  
 
Email *  
 

Your Professional Information

 
  I am a Health Care Professional
 
 

Professional Title

 
 

NPI#:

 
 

Specialty

 
  I am not  a Health Care Professional
 
 

Please select the most appropriate description below:

  I am a consumer/patient
  I am an investor
  Other: I am a  
 
 
    Please enter the word/numbers above in the "Type the text" field, then click on Submit.
         
     

    Medical Information

    Complete the form to submit a Medical Information Request or call the Corcept Medical Hotline 1-855-844-3270

    Adverse Reactions

    To report suspected adverse reactions, contact the Corcept Medical Hotline 1-855-844-3270

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