Get Started
Please provide the following information to assist us in getting started.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email (preferred method of communication)
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you over the age of 18?
*
Yes
No
Date of Birth:
*
-
Month
-
Day
Year
Date Picker Icon
Are you a legal US resident?
*
Yes
No
Have you been prescribed XYOSTED by your healthcare provider?
*
Yes
No
Are you uninsured at this time or have health insurance coverage that does not cover XYOSTED?
*
Yes
No
Communication Agreement
By submitting this form, I affirm that I meet the eligibility restrictions for the XYOSTED4YOU program available at https://xyosted.sterlingspecialtyrx.com and that the information I have provided is complete, true, and accurate to the best of my knowledge. I agree to comply with all terms and conditions of the program. I understand that I will be responsible for any and all shipping costs associated with a purchase made as part of this program. If I am a Medicare Part D beneficiary, I agree to allow Sterling Specialty Pharmacy to notify my Part D plan of my participation in this program.
Privacy Practices URL
https://sterlingspecialtyrx.com/privacy-practices/
Confirmation:
*
I have read and reviews Sterling Specialty Pharmacy's Privacy Practices (link above).
Submit
Should be Empty: