Please tick the relevant box
I don’t benefit from the LYSOSAFE Service,
please assist me in setting up the
LYSOSAFE Service
at my hospital/clinical practice.
I do benefit (or benefited in the past) from the LYSOSAFE Service
and would like to have online access to my patient’s mitotane plasma level results. Please give me access to
LYSOSAFE ONLINE
.
LYSOSAFE Registration Form
To reassure your registration, please complete all the boxes.
Last Name
First Name
Medical Specialty
Lysodren Prescriber
Yes
No
Phone (please include country code)
Fax (please include country code)
E-mail
Confirm E-mail
Please indicate how you would like us to send you the mitotane plasma results
e-mail + regular mail
fax + regular mail
I accept to receive access codes to LYSOSAFE ONLINE, which allows me to follow my patient(s’)s mitotane plasma levels at
www.lysosafe.com
. Your password and login will be sent to you by e-mail.
Yes
No
Hospital Name
Department
Street Name (PO Box not accepted)
Street Number
Postal Code
City
Country
Australia
Austria
Belgium
Bulgaria
Cyprus
Czech Republic
Danemark
Germany
Greece
Finland
France
Hungary
Ireland
Israël
Italy
Ivory Coast
Lithuania
Luxembourg
Maroc
Netherlands
Poland
Portugal
Romania
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Turkey
United Kingdom
Disclaimer
As per the EU Directive 95/46/EC requirements on data protection, you have the right to access and amend the information collected processed by HRA Pharma in the framework of the LYSOSAFE Service. To exercise this right, please send an email to
lysosafe@hra-pharma.com
Terms of use
LYSOSAFE Service is a free of charge mitotane plasma level testing service associated with the use of LYSODREN in patients with advanced Adrenal Cortical Carcinoma. LYSOSAFE allows the LYSOSAFE contact to frequently perform mitotane plasma level assays during LYSODREN treatment. Each sample result is validated by the LYSOSAFE assay manager. A specific certified result report is sent to the LYSOSAFE contact by email/fax and regular mail.
Access to LYSOSAFE ONLINE will enable the LYSOSAFE contact to have a complete historical overview of the mitotane plasma level results of their patient(s). However, the sample result mentioned on the specific certified result report should be considered as the validated and thus correct result.
Each LYSOSAFE contact registered for LYSOSAFE ONLINE will have access to the results of the patient(s) he/she recieves the specific result report for.
As per the EU Directive 95/46/EC requirements on data protection, you have the right to access and amend the information collected and processed by HRA Pharma under the framework of Lysosafe service. To exercise this right, please send an email to to
lysosafe@hra-pharma.com
Please Select
I hereby accept the terms of use and certify that the above information is true and complete
LYSOSAFE ONLINE Registration Form
To reassure your registration, please complete all the boxes.
Your password and login will be sent to you by e-mail.
Hospital Name
Department
City
Country
Australia
Austria
Belgium
Bulgaria
Cyprus
Czech Republic
Danemark
Germany
Greece
Finland
France
Hungary
Ireland
Israël
Italy
Ivory Coast
Lithuania
Luxembourg
Maroc
Netherlands
Poland
Portugal
Romania
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Turkey
United Kingdom
Last Name
First Name
E-mail
Phone (please include country code)
Disclaimer
As per the EU Directive 95/46/EC requirements on data protection, you have the right to access and amend the information collected processed by HRA Pharma in the framework of the LYSOSAFE Service. To exercise this right, please send an email to
lysosafe@hra-pharma.com
Terms of use
LYSOSAFE Service is a free of charge mitotane plasma level testing service associated with the use of LYSODREN in patients with advanced Adrenal Cortical Carcinoma. LYSOSAFE allows the LYSOSAFE contact to frequently perform mitotane plasma level assays during LYSODREN treatment. Each sample result is validated by the LYSOSAFE assay manager. A specific certified result report is sent to the LYSOSAFE contact by email/fax and regular mail.
Access to LYSOSAFE ONLINE will enable the LYSOSAFE contact to have a complete historical overview of the mitotane plasma level results of their patient(s). However, the sample result mentioned on the specific certified result report should be considered as the validated and thus correct result.
Each LYSOSAFE contact registered for LYSOSAFE ONLINE will have access to the results of the patient(s) he/she recieves the specific result report for.
As per the EU Directive 95/46/EC requirements on data protection, you have the right to access and amend the information collected and processed by HRA Pharma under the framework of Lysosafe service. To exercise this right, please send an email to to
lysosafe@hra-pharma.com
Please Select
I hereby accept the terms of use and certify that the above information is true and complete