• Prescribing Information  |
•   Important Safety Information

Get a 30-Day FREE Trial Offer* of AGGRENOX.

Sign up for your free trial voucher—and join the Taking Smart Steps^™ program, too!

The Taking Smart Steps™ program is a free resource designed to help you do more to reduce the risk of a subsequent stroke. As part of the program, you can look forward to:

• Education about ischemic stroke and TIA (transient ischemic attack)
• Resources to help learn about reducing the risk of a subsequent stroke
• Tips on diet and exercise
• Tips on talking to and partnering with the doctor

*60 capsules

Just complete the brief questions below to get your 30-Day FREE Trial Offer.

Also, don’t forget to check one of the boxes at the end of this form to enroll in the Taking Smart Steps™ program.

Required Information *

We’re sorry, but the fields indicated by an asterisk need to be completed.

First Name *
Last Name *
Address *
City *
State *	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY--  Zip Code *
Date of Birth *
Email *
Phone
	(e.g., 999-999-9999)

The following information is not required; however, it will help us to provide you with the most relevant
information based on your responses.

What is your gender?

Female

Male

I am a:

Patient

Caregiver

I (or my loved one) was diagnosed with a:

TIA (transient ischemic attack)

Stroke

I (or my loved one) was diagnosed:

Fewer than 3 months ago

More than 3 months ago

Are you (or your loved one) currently taking AGGRENOX?

Yes

No

What medication are you (or your loved one) currently taking to reduce the risk of recurrent stroke?

Aspirin

Plavix® (clopidogrel)

Other

I am not currently taking any medication

How would you like to receive future communications?

E-mail

Direct mail

The following questions are being asked by Boehringer Ingelheim Pharmaceuticals, Incorporated so that we may advertise our products to you and provide you with information about them.

We respect your right to have personal and medical information kept confidential. Companies working with us will use the information you provide to send you information and help develop products, services, and programs. If we provide you with coupons or vouchers for our products, the information we receive from the pharmacy regarding their use will also be used for the same purposes.

We won't share your private information with anyone else—including mailing lists.


Plavix® is a registered trademark of Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.

		By checking here and clicking "Sign Up" below, you indicate that you agree to the above and want us to use the information you have provided to send you information and offers relating to TIA/Stroke and AGGRENOX from time to time.
		By checking here and clicking "Sign Up" below, you indicate that you agree to the above and allow us to use your information to advertise TIA/Stroke and other products to you. Boehringer Ingelheim may also provide you with useful materials and contact you about health-related topics.

If you do not check either box, you will NOT be enrolled in the Taking Smart Steps^™ program and you will only receive your voucher for a 30-Day FREE Trial Offer of AGGRENOX.

*60 capsules

Click here for full Prescribing Information, including Patient Information.

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