RapidSource Product Form

Rapid Sourcing Enquiry

In which country/region are you located? AustraliaNew ZealandAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChinese TaipeiChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCura莽aoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarRepublic of KoreaReunionRomaniaRussian FederationRwandaSaint Barth茅lemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishWallis and FutunaWestern SaharaYemenZambiaZimbabwe

First name:

Last name:

Company name:

Business email address:

Business phone (inc country code and area code, i.e. +61300000000):

Are you a healthcare professional? Yes I am a Healthcare ProfessionalAuthorised Non Healthcare ProfessionalPatient/ConsumerOther

Full legal entity name:

What’s your healthcare/business role or function? Administration and SupportAssistantAged Care Nurse PractitionrAged Care PhysicianAllied health professionalBilling SpecialistNurse MidwifeChemistNurse SpecialistCoding SpecialistCustomer ServiceDistributionDietitianEngineerFinanceDoctorGeneral PractionerGovernanceHospital/Practice StaffHuman ResourcesInformation TechnologyLaboratory and DiagnosticsManagementMarketing and CommunicationsMedical InformationMedical AssistantJournalist/MediaMedical RecordsNon-Prescribing Health Care ProfessionalNurseNurse ManagerTheatre NurseTheatre Registered NurseTheatre TechnicianOperationsOtherParamedicPharmacistPharmacy TechnicianPhysio TherapistPhysicianPhysician AssistantPrivate PayerInsuranceProcurement/SourcingProductionQualityRadiologyResearch and DevelopmentSpecialistScientistStrategySurgeonTechnician

HCP license number:

Licensed country: AustraliaNew ZealandUnited StatesCanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d’IvoireDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaViet NamWallis and FutunaWestern SaharaYemenZambiaZimbabwe

Licensed state:

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What's your specialty area (if applicable otherwise select: no specialty): Allergy and ImmunologyAnaesthesiologyCardiologyDentistsDermatologyDiabetesEar, Nose and ThroatEmergency MedicalEndocrinologyEpileptologyEye/OphthalmologistFamily PracticeGastroenterologyGeneral PracticeGeneral SurgeryGeriatricsInternal MedicineInterventional RadiologyNeurologyNeuropsychologyNeurosurgeryNo specialityNutritionObstetrician-GynaecologistsOccupational TherapyOncologyOrthopaedic SurgeryOrthopaedicsPain ManagementPalliative CarePathologyPaediatricsPerfusionPhysiatry/PM&RPhysiotherapyPsychiatryRadiologyRehabilitationRenalRespiratoryRheumatologySurgery-CardiothoracicSurgery-CardiovascularSurgery-ColorectalSurgery-GeneralSurgery-OrthopaedicSurgery-PlasticsSurgery-Podiatry / PodiatricSurgery-ReconstructiveSurgery-VascularUrogynecologyUrologyVeterinarianProsthetics

What is your product interest: S19A ProductsSpecial Access Scheme (SAS)Registered ProductsClinical TrialsOver the counter (OTC)Animal Health ProductsMedical DevicesCompounding

Generic name/Active Ingredient:

Brand name:

Dose strength (if unknown select any):

Pack size:

Dosage form: AllogenicApplicationAutologousBar, soapBlockCapsuleCapsule soft entericCapsule, entericCapsule, hardCapsule, modified releaseCapsule, softCement, medicatedChipsChips, CoarseChips, FineChips, LargeChips, MediumCollodionCone, dentalCreamCrushedCryopreservedDecellularisedDehydratedDemineralisedDevice gelDevice, aerosolDevice, drug coated (in house only)Device, effervesent tabletDevice, powderDevice, solutionDevice, sprayDevice, tabletDevice, wipeDiluent, not applicableDirectedDressing, medicatedDrug delivery systemDrug delivery system, intrauterineDrug delivery system, ocularDrug delivery system, transdermalDrug delivery system, vaginalEar DropsEar Drops, emulsionEar Drops, powder forEar Drops, solutionEar Drops, suspensionEnemaEssential OilExtractExtract, concentratedExtract, dryExtract, liquidExtract, softEye and Ear DropsEye and Ear OintmentEye DropsEye Drops, emulsionEye Drops, powderEye Drops, solutionEye Drops, suspensionEye OintmentFibularFreeze dried (Lyphilised)Fresh Frozen Cryopreserved Lyophilised encapsulatedFrozenFuCellGas, medicinalGelGel, eyeGel, modified releaseGraftGranulesGranules, effervescentGranules, enteric-coatedGranules, modified releaseGum, chewingHerb, driedImplantImplant, radioactiveInhalationInhalation, conventionalInhalation, powder forInhalation, pressurisedInjectionInjection, concentratedInjection, diluent forInjection, emulsionInjection, intravenous infusionInjection, powder forInjection, solutionInjection, solvent forInjection, suspensionInsufflationLarge Volume ParenteralLinimentLiquid, multipurposeLiquidsLiquids, suspensionsLiquids, tincturesLotionLozengeLozenge with integral applicationMicronisedMicronised DehydratedMilledMineralisedMouthwashNasal DropsNasal Drops, emulsionNasal Drops, powder forNasal Drops, solutionNasal Drops, suspensionOilOral LiquidOral Liquid, powder forOral Liquid, suspensionOral Liquid, syrupPad, impregnatedPaintPaint, concentratedPaint, powder forPastePastillePatch, dermalPessaryPessary, compressedPessary, modified releasePessary, mouldedPessary, shellPillPowderPowder, dustingPowder, dusting, sterilePowders and granulesScratch test unitSoft TissueSoluble FilmSolutionSolution, concentrated dialysisSolution, dialysisSolution, irrigationSolution, powder forSolution, powder for dialysisSolution, powder for irrigationSpraySpray, nasalSpray, pressurisedSpray, solutionSpray, suspensionStickStick, lipStick, uretheralStructural AllograftsSuppositories and pessariesSuppositorySuppository, compressedSuppository, mouldedSuppository, shellSuspensionSuspension, powder forTabletTablet, chewableTablet, dispersibleTablet, effervescentTablet, enteric coatedTablet, film coatedTablet, gelatin coatedTablet, modified releaseTablet, multilayerTablet, orally disintegratingTablet, solubleTablet, sugar coatedTablet, uncoatedTinctureTopicalTopical sunscreen forms, liquidsTopical sunscreen forms, wipesUnicorticalWaferWipe, medicated

Pharmaceutical presentation: A shallow, typically round container, covered with either a wrapping or a lidAerosol - Pump ActuatedAerosol - Pump Actuated Metered DoseAerosol CanAerosol Can - Metered DoseAmpouleBagBlister PackBottleBottle, with integral pump - manual actuatedBuffer PackBulk ContainerCartonCartridgeCompactDeviceDial Dispenser PackDispenser PackDrumGas CylinderInformation not keyed in during fast trackingInformation not supplied by sponsorInhaler - dry powderInhaler - Metered DoseJar/CanMultiple containersNasal applicatorNot ApplicablePouchPuffer PackSachetShrink WrapSpray - elasticity drivenStrip PackSyringeTea BagTubeVialVitrellaWrapping

Required quantity (Please provide us with the required quantity for accurate pricing and stock availability - if unknown, select unknown):

Acceptable target price (Please advise a price range that is acceptable. This will help us to ensure that we are aligning our sourcing efforts with your expectations):

Does this product have a Marketing Authorisation in your country? NoYes, but is on short supply.Yes, but is not being commercialised by its sponsor.Yes, but it is going to be discontinued.Yes, but I need a specific dose form.Unsure

Is this product for a patient with a clinical need which cannot be met by a licensed product in your country? YesNoUnsure

Is this a controlled drug in your country? YesNoUnsure

Are there any compulsory documents you need to be provided to import this product into your country? YesNoUnsure

Which territories are you willing to accept products from? European Economic Area and Mutual Recognition Agreements (Australia, Canada, Israel, Japan, New Zealand and Switzerland).United States of AmericaThird World

Sourcing urgency: Hospitalised patient – ImmediateCriticalHighMediumLow

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