SIGN UP TO SPEAK WITH A MENTOR

Fill out this short form to connect with one of our DUPIXENT MyWay® Mentors.

Tell us about yourself

We just need you to answer a few questions to verify your eligibility and contact information.

Note: All information is required unless otherwise indicated.

Your Birthdate
Age Range of Patient:

Patient must weigh at least 33 lb (15 kg)

Find a mentor

Fill out the questions below to help us find the best Mentor for you.

Note: All information is required unless otherwise indicated.

Do you have a DUPIXENT prescription?
Discussion Topics (Choose All That Apply):
Language Preference:

Communication Preferences

Fill out the questions below to set up the best time to meet with a Mentor.

Note: All information is required unless otherwise indicated.

Which Day(s) Work Best for Calls? (Select All That Apply):
Which Times Work Best for Calls? (Select up to 3):
Select Your Time Zone
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How Did You Hear About the Program?
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Additional Communication Preferences:

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