INTERNATIONAL ASSOCIATION OF PHYSICIANS IN AIDS CARE
225 West Washington Street, Suite 2200, Chicago, Illinois 60606
Fax: 312 419-7160
IAPAC NORVIR ADVISORY
Document: Eligible Provider Enrollment Request
Definition of Eligible Provider:
The IAPAC Norvir Advisory defines an "Eligble Provider" as a "physician prescribing ritonavir, or a pharmacist who dispenses ritonavir prescriptions, who does not have access to the Internet."
Please type or print.
Please print - (First) (Middle) (Last)
I meet the definition of "Eligible Provider."
Please check one:
( ) I am a physician with approximately __________ patients on ritonavir.
( ) I am a pharmacist who dispenses ritonavir to approximately _____ patients.
Please send me a print copy of the IAPAC Norvir Advisory via (please check one)
( ) FAX (please indicate fax number )_______________________________
( ) Mail Address:__________________________________________________
(Organization, if applicable)
(Country) (Zip/Mail Code)
I understand that although updates may be made on the IAPAC Norvir Advisory daily, print copies can only be sent weekly.