For US Healthcare Professionals

My QUTENZA Connect Practice Registration

Fill out the form to register your practice in the My QUTENZA Connect Savings Program.

To secure your privacy, this session will time out if left idle for 15 minutes. Information will not be saved and you will need to restart registration.

NATIONAL PROVIDER IDENTIFIER (NPI)

Auto populate form with NPI. (If NPI does not auto populate, please fill in the remaining fields.)

All fields marked with * are required

PRACTICE

USER

PRESCRIBER

Once all the required fields are populated, click "Submit Registration." This will prompt the support team to contact your practice to confirm the information provided. To reach a support team member directly, call 855-802-8746.

By clicking on the "Submit Registration" button, you agree that the information you provide will be governed by our site Privacy Policy.