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For questions about financial assistance, call 1-844-DUPIXENT, option 1 or
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DUPIXENT is a prescription medicine used to treat adults with prurigo nodularis (PN). It is not known if DUPIXENT is safe and effective in children with PN under 18 years of age.

mentor request form

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.

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:

I acknowledge that by checking the checkbox, I consent to receive text messages from Sanofi regarding DUPIXENT at the mobile telephone number that I provide. Message and data rates may apply. I understand that I can opt out at any time by texting STOP and I can get help by texting HELP to 94742. Message frequency will vary. I understand that my consent is not required as a condition of purchasing any goods or services.

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