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Consumer Request

All fields marked with * must be completed

I am submitting this request *
If applicable:
How do you want to receive our response to your request (or any other request-related communications)? *
Request type *

This information will be used to process your request and for no other purpose. LEO Pharma will maintain a record of your request pursuant to applicable law.


We may require additional information to verify your identity prior to fulfilling your request. If you are an authorized agent submitting a request on behalf of another consumer, you must attach proof that you have been authorized by the consumer to operate on his/her behalf when you reply to the verification email (i.e., a valid power of attorney executed by the patient).


By clicking submit:

  • I attest under penalty of perjury that I am the consumer whose personal information is the subject of the request or am the authorized agent submitting this request on behalf of that consumer.
  • I understand that after submitting this request, I will receive a verification email to confirm my request and must respond to the email with “I approve” in order for my request to be processed.
Certification *
Data protection *

Please send an email to if you have any questions or technical issues with this form.

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