Alpha Cognition Medical Affairs

This form is not intended to report adverse events or product quality complaints.

To report an adverse event or product quality complaint, you may:

Call 1-877-257-4203 (Option 4)

Report directly to the FDA at 1-800-FDA-1088 or visit www.fda.gov/medwatch

Required fields are marked with an asterisk (*)

Your Inquiry

Select the Product for your Inquiry:*

Please indicate how you would like the response to your question(s) delivered:*

Phone

Your Question for Alpha Cognition Medical Affairs

Your Contact Information

Select the option that best describes you:*

First Name *

Last Name *

Facility/Clinic:*

Address:*

City:*

State:*

Zip Code:*

Email Address *

Telephone Number:*

This form is intended to be used by licensed US healthcare professionals to request information from US Medical Affairs at Alpha Cognition. This form is not intended to collect personally identifiable health information and any response given should not be construed as medical advice for a particular patient.

By clicking SUBMIT you are confirming that your question(s) are unsolicited, and that you have read and agreed to Alpha Cognition's Legal and Privacy Policy, and that the wording above accurately states your request(s) and/or question(s), and awareness that per the Physician Payment Sunshine Act, article reprints are a reportable item of value.

Medical Inquiry Form