MIRAPEX For HEALTHCARE Professionals

Registration

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Now, people with RLS can get lifestyle tips, details about MIRAPEX, and receive a FREE MIRAPEX 10-day trial offer. Just fill out the following questionnaire to become a part of our free patient information program.

*Required fields
*First Name:
*Last Name:
Telephone:
*Email Address:
*Date of Birth:
*Address 1:
Address 2:
*City:
*State:
*Zip Code
*Gender

Please tell how you would prefer us to contact you:
Email
Postal mail
No preference

Describe yourself:
Restless legs syndrome (RLS) patient
RLS caregiver
Healthcare professional
Unsure if you have RLS
Other

How often do you experience RLS symptoms?
Every day
5-6 days a week
3-4 days a week
1-2 days a week
2-3 times a month
Rarely/never

What are you currently using to treat your RLS symptoms (check all that apply)? Trademarks are the property of their respective owners.
Requip ®
Mirapex ®
Prescription sleep aids
Other prescription
Over-the-counter sleep aids
Other

If you're taking MIRAPEX, how long have you been on it?
0-3 months
4-6 months
6-12 months
Over 1 year

Do you plan to talk to your healthcare professional about RLS at your next visit?

Yes
No
Don't know

Boehringer Ingelheim Pharmaceuticals, Inc. respects your right to have personal and medical information kept confidential. Boehringer Ingelheim and companies working with Boehringer Ingelheim will use the information you provide to fulfill your request. It will not be shared with any other third parties (such as mailing lists).

By checking here and clicking "Submit" below, you indicate that you want us to use the information you have provided to send you information and offers.

By checking here and clicking "Submit" below, you also agree to allow us to use your information to advertise other products to you. Boehringer Ingelheim and companies working with Boehringer Ingelheim may use your information to help develop products, services, and programs.

Boehringer Ingelheim may also provide you with useful materials and contact you about health-related topics.

If you do not check either box, we will fill just this one-time request.

You are about to submit the following information. Please click "Submit" to verify that all answers are correct. If you need to make changes, click “Clear Form” to do so.

Interactive Activities

Try our online activities and interactive quiz to test how much you know about RLS.

Interactive Quizzes

Online Symptom Checklist

Wondering if you have RLS? Check out the Symptom Checklist!

Wondering if you have RLS? Check out the Symptom Checklist!

IMPORTANT SAFETY INFORMATION ABOUT MIRAPEX: MIRAPEX tablets are indicated for the treatment of moderate-to-severe primary Restless Legs Syndrome (RLS).

MIRAPEX may cause you to fall asleep without any warning, even while doing normal daily activities, such as driving. When taking MIRAPEX, hallucinations may occur and sometimes you may feel dizzy, sweaty or nauseated upon standing up. The most common side effects in clinical trials for RLS were nausea, headache, and tiredness. You should talk with your doctor if you experience these problems.

Patients and caregivers should be informed that impulse control disorders/compulsive behaviors may occur while taking medicines, including pramipexole, to treat Parkinson's disease and RLS.

This information is intended for U.S. residents only. Products discussed herein may have different labeling in different countries.

Please see full Prescribing Information, including patient information.

If you can't afford your MIRAPEX, our patient assistance program may be able to help. Call 1-800-556-8317

If you can't afford your MIRAPEX, our patient assistance program may be able to help. Call 1-800-556-8317
Boehringer Ingelheim