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IMLYGIC® Customer Registration

IMLYGIC® (talimogene laherparepvec) Customer Registration

This information is being collected to develop your account’s IMLYGIC® shipping profile. You only need to register once. However, if your account information changes, please complete the registration form again so we can have the most up-to-date information for your IMLYGIC® orders. If you have any questions, please call 1-866-IMLYGIC and select Option 1 for Healthcare Professionals then select Option 2 for Ordering.

Required

Required

Please enter a first name of the IMLYGIC® contact person at your clinic/institution.

Required

Please enter a last name of the IMLYGIC® contact person at your clinic/institution. Please enter a valid city. Please choose a state. Please enter a valid zip code.

Please enter your clinic/institution’s HIN or DEA number. Only one is required.
This number should align to the account information of the ordering entity.

Please enter a valid number Please enter a valid number

Required

Please enter a valid customer email address.
Optional Please enter a valid customer email address.
Optional Please enter a valid customer email address.
Optional Please enter a valid customer email address.
Optional Please enter a valid customer email address.

IMLYGIC® is shipped in a container that will maintain appropriate temperature for 4 days. Amgen has an IMLYGIC® freezer program for purchasers that do not have available freezers appropriate for storing the product. If you would like additional information, please call 1-866-IMLYGIC (1-866-465-94421-866-465-9442)

Thank you for registering.

You will receive a confirmation email in the next 2-3 business days.



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