{"id":49,"date":"2025-06-19T19:01:36","date_gmt":"2025-06-19T19:01:36","guid":{"rendered":"https:\/\/firdapsehcp-calems.local\/calems\/?page_id=39"},"modified":"2025-07-09T15:34:21","modified_gmt":"2025-07-09T15:34:21","slug":"request-a-rep","status":"publish","type":"page","link":"https:\/\/firdapsehcp.com\/ca-lems\/request-a-rep\/","title":{"rendered":"Request a Rep"},"content":{"rendered":"\n<div class=\"wp-block-emagine-background alignfull has-gray-xl-background-color has-background-dim em-pt--lg em-pb--lg is-style-lines-at-bottom has-background em-pt--lg em-pb--lg\"><div class=\"wp-block-emagine-background__content\"><div class=\"wp-block-emagine-background__content-inner\">\n<h1 class=\"h1\">GET IN TOUCH WITH YOUR FIRDAPSE REPRESENTATIVE<\/h1>\n\n\n\n<p class=\"has-medium-font-size\"><strong>Fill out the information below, and your personal FIRDAPSE&nbsp;Team Member will reach out shortly.<\/strong><\/p>\n\n\n\n<p class=\"has-small-font-size\"><em>*Required fields.<\/em><\/p>\n\n\n\t\t\t\t<div id=\"block_fe517ffd3bf8692d466e8cbfc0be7767\" class=\"wp-block em-rounded-corner-block em-mt--none em-mb--md alignwide\">\n\t\t\t\t\t\t\t\t\t\t\n\n<div class=\"em-rounded-corner-block__wrapper has-none-background-color no-mobile-styles\">\n\t\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in 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gfield_required_custom\">*:<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/ca-lems\/wp-json\/wp\/v2\/pages\/49' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_16\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Name<\/label><div class='ginput_container'><input name='input_16' id='input_1_16' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_16'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*:<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*:<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>NPI Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>Business\/Practice Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*:<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_1_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Business\/Practice ZIP Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*:<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*:<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_1_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Type of Healthcare Provider<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*:<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_1_10' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select one' >Select one<\/option><option value='Oncologist' >Oncologist<\/option><option value='Oncology Nurse' >Oncology Nurse<\/option><option value='Neurologist' >Neurologist<\/option><option value='Neuromuscular Specialist' >Neuromuscular Specialist<\/option><option value='Primary Care \/ Internal Medicine' >Primary Care \/ Internal Medicine<\/option><option value='Physical Medicine and Rehabilitation' >Physical Medicine and Rehabilitation<\/option><option value='Nurse Practitioner' >Nurse Practitioner<\/option><option value='Physician Assistant' >Physician Assistant<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>LEMS Experience<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*:<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_1_11' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select one' >Select one<\/option><option value='I currently treat patients with LEMS' >I currently treat patients with LEMS<\/option><option value='I have diagnosed and treated LEMS in the past' >I have diagnosed and treated LEMS in the past<\/option><option value='I have not treated a patient with LEMS but am aware of the disease and what to look for' >I have not treated a patient with LEMS but am aware of the disease and what to look for<\/option><option value='This is the first time I&#039;ve heard of LEMS' >This is the first time I&#039;ve heard of LEMS<\/option><\/select><\/div><\/div><fieldset id=\"field_1_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reasons for contact (select all that apply)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*:<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_12'><div class='gchoice gchoice_1_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='I want information on a LEMS test'  id='choice_1_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_1' id='label_1_12_1' class='gform-field-label gform-field-label--type-inline'>I want information on a LEMS test<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='I may have a LEMS patient'  id='choice_1_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_2' id='label_1_12_2' class='gform-field-label gform-field-label--type-inline'>I may have a LEMS patient<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='I want more FIRDAPSE information'  id='choice_1_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_3' id='label_1_12_3' class='gform-field-label gform-field-label--type-inline'>I want more FIRDAPSE information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='I want patient savings information'  id='choice_1_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_4' id='label_1_12_4' class='gform-field-label gform-field-label--type-inline'>I want patient savings information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='I want to schedule time with a LEMS expert'  id='choice_1_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_12_5' id='label_1_12_5' class='gform-field-label gform-field-label--type-inline'>I want to schedule time with a LEMS expert<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Catalyst Pharmaceuticals respects your personal information. The information you provide may be used to send you health-related materials and to develop products, services, and programs. Catalyst Pharmaceuticals or third parties working on our behalf will not sell or rent personal health information. Your information will only be used in accordance with the Catalyst Privacy Policy.\n<\/br><\/br>\nIf you later wish to opt out of receiving this information, you may click on the included opt\u2011out link in future communications.\n<\/br><\/br>\nBy completing this registration, you confirm that you are 18 years of age or older and a US resident.<\/div><div id=\"field_1_14\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>CAPTCHA<\/label><div id='input_1_14' class='ginput_container ginput_recaptcha' data-sitekey='6Lf0u8QrAAAAAN554dvFApsLzAUyr9jjt0DQ3gX0'  data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button  type='submit' 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