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.

Account Name

Name of your clinic/institution.x

Required

Please enter an account name.

First Name

First Name of the IMLYGIC^® contact person at your clinic/institution.x

Required

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

Last Name

Last Name of the IMLYGIC^® contact person at your clinic/institution.x

Required

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

Address

City

Please enter a valid city.

State

Please choose a state.

Zip Code

Please enter a valid zip code.

Telephone Number

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.

HIN Number

Your HIN number is a 9-character alphanumeric.x

Please enter a valid number

DEA Number

Please enter a valid number

Email Addresses

Please enter an email address or addresses that you would like to receive IMLYGIC^® shipment tracking information. Only one email address is required.x

Required

Please enter a valid customer email address.

Optional Please enter a valid customer email address.

Does your clinic/institution have an ultra-low freezer -90°C to -70°C (-130°F to -94°F) to store IMLYGIC^®?

Yes No

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.

RETURN TO IMLYGIC.COM >

IMLYGIC® Customer Registration

IMLYGIC® (talimogene laherparepvec) Customer Registration

Thank you for registering.

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

IMLYGIC^® Customer Registration

IMLYGIC^® (talimogene laherparepvec) Customer Registration