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Fax to: 1.866.867.4962 Patient Informational (First, MI, Last, Suffix):(Please print)Address:(Please circle preferred phone number)State:Phone: 1.855.GLATOPAPRESCRIPTION AND SERVICE REQUEST FORM Date

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What is for review s-gla-1342783 glatopa?

It is a medication used to treat relapsing-remitting multiple sclerosis.

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Patients or healthcare providers may file for review of glatopa.

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The purpose is to ensure the safety and effectiveness of glatopa for its intended use.

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Information such as patient data, adverse reactions, dosage, and treatment outcomes must be reported for review of glatopa.

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