Application form

All fields below are mandatory unless otherwise stated.

By signing and submitting this form, you confirm that all details provided are accurate and that they belong to you, and that you have obtained consent from your professional sponsor to share their personal information with Novartis. Your personal information will be processed in accordance with the Novartis General Privacy Notice for Business Partners (novartis.co.uk/privacy-policy). Your personal information will be processed for Novartis’ legitimate interests in organising and managing the programme. Please contact your Novartis representative should you have any questions.

The MPN Leaders Programme is organised and funded by Novartis Pharmaceuticals UK Ltd and is classed as promotional under the Association of the British Pharmaceutical Industry (ABPI) Code. Prescribing information will be available throughout the programme for all Novartis brands mentioned. Participation in the programme will be funded by Novartis (delegate travel, accommodation and reasonable expenses will be covered in the event of a face-to-face meeting). The Steering Committee has been offered an honorarium for their involvement in this programme.

HCP20-C048c October 2020.
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Medical Information Request

Adverse events should be reported. Reporting forms and information can be found at yellowcard.mhra.gov.uk. Adverse events should also be reported to Novartis via [email protected] or online through the pharmacovigilance intake (PVI) tool at http://www.report.novartis.com/
If you have a question about the product, please contact Medical Information on 01276 698370 or by email at [email protected]