Refill reminder

To maintain the benefits of FLOMAX and help control your male urinary symptoms due to BPH, it is important that you keep taking FLOMAX. To help you remember to refill your prescription, sign up here to receive reminders by Email or mail.

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I would like to receive my reminders by (select one)
Email Mail
First Name*
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Please provide your email address:

Select the day of the month on which you would like to be reminded by clicking on it. Then select the frequency of your reminder (30 or 90 days). You will receive your first reminder 30 or 90 days from the date you select.
Date*

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	By checking here and clicking the “Sign Up” button below, you indicate that you want us to use the information you have provided to send you information and offers relating to BPH and FLOMAX from time to time.
	By checking here and clicking the “Sign Up” button below, you also agree to allow us to use your information to advertise other products to you. Boehringer Ingelheim and companies working with them may use your information to help develop products, services and programs. They may also provide you with useful materials and contact you about health-related topics.

If you do not check either box, we will send you just the refill reminders.

This information is being collected by Boehringer Ingelheim Pharmaceuticals, Inc. so that we may advertise our products to you and provide you with information about them.

Boehringer Ingelheim Pharmaceuticals, Inc. respects your right to have personal and medical information kept confidential. Boehringer Ingelheim and companies working with Boehringer Ingelheim will use the information you provide to fulfill your request. It will not be shared with any other third parties (such as mailing lists).

You are about to submit the following information. Please click “SUBMIT” to verify that all answers are correct. If you need to make changes, click “Clear Form” to do so.

Click here to see an example of the email.

I confirm that I am at least 18 years of age.