Medical Request REQUEST A MEDICAL AFFAIRS FOLLOW-UP This form is ONLY for requesting a contact for Veltassa® or Korsuva® related questions, or for general disease state information by a U.S. healthcare professional. Patients should always talk with their healthcare team if there are any questions about their individual treatment. Attention Adverse Effects Reporting: This form is not for reporting information about any medication side effects. To report suspected adverse reactions, contact Vifor Pharma at 1-844-735-9772. If you prefer you may contact the U.S. Food and Drug Administration directly at www.fda.gov/medwatch or call 1-800-FDA-1088. Please complete all required fields below. Your request will be submitted to Vifor Pharma Medical Affairs, and you will be contacted accordingly. First Name * Last Name * Email * Phone Number * City * state fieldset State State State/Province State Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon fieldset job Job Title * Job Title CAPTCHA Math question 1 + 2 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. prefer contact fieldset How do you prefer to be contacted * - Select - Email Phone