Genetic test request form

Do you recall seeing patients with uncertain muscular weakness in recent months?

Yes

Do you take into consideration SMA in these cases?

Yes

Would you like to request a free Genetic Test to diagnose SMA?

Yes

Please fill out the fields to request the Genetic test

Name

Surname

Speciality

Hospital/Institution

City

Country:

Email address

Phone number

Consent

By checking this box, you agree that Biogen and its group companies can send you business-related communications, such as updates about Biogen, therapy information, insights about diseases, clinical trial information, patient education materials and invitations to participate in surveys, events and webinars. It is your free decision whether you provide your consent, and you may withdraw consent and opt-out of these communications at any time.

You can find more information about the processing of your personal data by visiting Privacy Policy and clicking on “Healthcare Professionals Privacy Notice”.

*Your request for a genetic test will not guarantee that it will be provided. A Biogen representative will contact you to evaluate if a genetic test is the right course of action.

Thank you!

In case of SMA suspicion, you can request the genetic test anytime.

More info on SMA