Intended for U.S. healthcare professionals only. For corporate information, please visit Mallinckrodt.com X
  • Child Safety Kit Order Form

    If you would like to order a Child Safety Kit, please fill out the following form.

    Please be aware that signing up for this program is voluntary. If you are a patient, a Mallinckrodt staff pharmacist may follow up with you in order to answer any questions you may have about the product. Mallinckrodt will keep your personal information safe and will not sell or transfer it to others.

    First Name * 

    Last Name * 

    Company Name * 

    Address 1 * 

    Address 2 

    City * 

    State * 

    Postal Code * 

    Telephone * 

    Fax 

    Email 

    Physician Name 

    Physician Phone

    Comments 
     

    * - Denotes a required field

    We want you to know we respect your privacy and your information.