Request a DHR Collection Kit (DHR Test) for CGD

Please check one option below.

Request a Representative: Speak with a representative to learn more about a treatment option for chronic granulomatous disease (CGD).

Request a DHR Test Kit: If you suspect CGD in a patient or would like to determine carrier status, the Dihydrorhodamine (DHR) Collection Kit is being offered at no cost from Amgen.

Requester (All fields are required)

Enter 10-digit NPI number *

Please enter valid 10 digit NPI number

You can expedite the sign-up process by looking up your National Provider Identification number.

Please enter first name

Please enter last name

Please enter valid email

Please enter valid confirm email

Must match your entered email.

Please select your specialty

Nature of request required.

Shipping address for your practice (All fields are required)
Do not ship kits directly to your patient(s).

Please enter Practice name

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Please enter Practice name

Please enter state

Please enter Zip Code

Please enter Attention

Please enter Practice Phone Number

DHR Test Kit Quantity

1 2 3

Response Required

Specimen Collection Kits – Terms & Conditions of Acceptance

These Terms & Conditions of Acceptance shall apply in the event you (as a licensed prescriber) accept receipt of one or more Specimen Collection Kits from or on behalf of Amgen. Your acceptance of one or more such kits shall indicate that you will adhere to all of the following terms and conditions:

1. The Specimen Collection Kits will be used only upon the order of a licensed prescriber.

2. The Specimen Collection Kits will be used at no cost to patients. To be clear, neither you nor anyone else will sell or otherwise charge for the products or services associated with the Specimen Collection Kits.

3. Neither you nor anyone else will seek reimbursement from any third-party payor for the contents of the Specimen Collection Kit, or for the services rendered when using the Specimen Collection Kit. To be clear, neither private payors nor federal or state healthcare programs will be billed for any products or services associated with the Specimen Collection Kit.

By clicking this box, I agree to the Terms & Conditions of Acceptance for Specimen Collection Kits stipulated by Amgen.

Privacy Notice and Consent: I understand I am giving Amgen, its affiliates, subsidiaries and business partners permission to use and disclose the personal information provided in this registration form, as described in this authorization. I understand that the information I am providing may be used by Amgen to provide me with health and product information and related services concerning health conditions and treatments, and that Amgen will treat my information in accordance with its Privacy Policy. I agree that this authorization will expire ten (10) years from the date submitted, or until I withdraw my participation in the program. I acknowledge that I am submitting this form voluntarily, and that I am at least 18 years of age.

I agree to the Terms and Conditions.

You must agree to the Terms and Conditions.

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