New Customer Application

Use the following forms to create a new customer account with Varithena®:

  • Business Application: Please use this document to set up a direct account with BTG.
 
  • Letter of Affiliation (LOA): This document provides authorization to ship Varithena® product to the address listed on the form
 
Use this form instead of the LOA above if you are licensed in the state of Florida (scroll down past LOA for the DOI)
  • Declaration of Intention (DOI): This document provides authorization to ship Varithena® product to the address listed on the form for residents of Florida

 

If you would like materials to help tell your patients about Varithena® including patient brochures, posters, press release templates and web announcements, please Contact Us or discuss with your Varithena® Sales representative.

 

Business Application and Letter of Affiliation


Business Application and Declaration of Intention (State of Florida Only)


Contact your Territory Sales Manager for more information.
1-855-971-VEIN (8346) Monday through Friday, 8 am to 8 pm ET

CONTACT BOSTON SCIENTIFIC

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

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