Medical Information Request

Instructions: This form is intended for use by trained CrossLink representatives regarding questions from US Medical Professionals only. Fields marked with an asterisk (*) are mandatory.

*CrossLink Representative Information

Healthcare Professional Information

Requestor’s Title:

Degree:

*Preferred Contact Method:

Email Phone

Unsolicited Medical Information Request for ZYNRELEF^® (bupivacaine and meloxicam) extended-release solution

*Medical Information Inquiry/Question:

I certify that I am submitting this question on behalf of a healthcare professional who reactively asked a medical information question, and they understand that the information provided to them will be used by Heron Therapeutics and/or its contracted third parties to contact them with relevant information. Adverse Events (AEs) and Product Complaints (PCs) should not be reported through this form. Please report all AEs and PCs by calling 1-844-HERON11 (437-6611).

A signature will not be collected on this form.

Medical Information Request

Thank You!

*CrossLink Representative Information

Healthcare Professional Information