{"id":3490,"date":"2024-07-25T09:01:19","date_gmt":"2024-07-25T09:01:19","guid":{"rendered":"https:\/\/hcp.biomarin.com\/en-us\/voxzogo2\/?page_id=3490"},"modified":"2024-07-25T09:01:19","modified_gmt":"2024-07-25T09:01:19","slug":"rep-connect-registration-form","status":"publish","type":"page","link":"https:\/\/hcp.biomarin.com\/en-us\/voxzogo\/rep-connect-registration-form\/","title":{"rendered":"Rep Connect Registration Form"},"content":{"rendered":"<div id=\"acf-block-6447dc90e3f67\" class=\"block hcp-sign-up-form\">\n    <div class=\"wrapper\">\n        <div class=\"inner-wrapper\">\n                            <h2>Connect With a BioMarin Representative\n<\/h2>\n                        \n            <div class=\"block form-box\">\n                <p>*Required fields<\/p>\n                <form id=\"hcp-sign-up\" name=\"Stay up to date\">\n                    <div class=\"form-columns\">\n                        <div class=\"form-item\">\n                            <label for=\"first-name\">First name<span class=\"required\">*<\/span><\/label>\n                            <input class=\"text\" id=\"first-name\" type=\"text\" required\n                            data-pristine-required-message=\"Please enter your first name\">\n                        <\/div>\n\n                        <div class=\"form-item\">\n                            <label for=\"last-name\">Last name<span class=\"required\">*<\/span><\/label>\n                            <input class=\"text\" id=\"last-name\" type=\"text\" required\n                            data-pristine-required-message=\"Please enter your last name\">\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"form-item\">\n                        <label for=\"email\">Email<span class=\"required\">*<\/span><\/label>\n                        <input class=\"text\" id=\"email\" type=\"email\" required\n                        data-pristine-required-message=\"Please enter your email address\">\n                    <\/div>\n\n                    <div class=\"form-item\">\n                        <label for=\"zip-code\">US postal code<span class=\"required\">*<\/span><\/label>\n                        <input class=\"text\" id=\"zip-code\" type=\"text\" required\n                        data-pristine-required-message=\"Please enter your ZIP code\"\n                        data-pristine-pattern-message=\"Please enter a valid ZIP code\"\n                        data-pristine-pattern=\"\/^\\d{5}(-\\d{4})?$\/i\">\n                    <\/div>\n                    \n                    <div class=\"form-item\">\n                        <label for=\"medical-speciality\">Specialty<span class=\"required\">*<\/span><\/label>\n                        <select class=\"text\" id=\"medical-speciality\" required\n                        data-pristine-required-message=\"Please select your specialty\">\n                            <option value=\"\">Select your specialty<\/option>\n                            <option value=\"Audiology\">Audiology<\/option>\n                            <option value=\"Behavioral Neurology &amp; Neuropsychiatry\">Behavioral Neurology &amp; Neuropsychiatry<\/option>\n                            <option value=\"Cardiology\">Cardiology<\/option>\n                            <option value=\"Clinical Biochemical Genetics\">Clinical Biochemical Genetics<\/option>\n                            <option value=\"Diagnostic Radiology\">Diagnostic Radiology<\/option>\n                            <option value=\"Electroencephalography\">Electroencephalography<\/option>\n                            <option value=\"Endocrinology, Diabetes &amp; Metabolism\">Endocrinology, Diabetes &amp; Metabolism<\/option>\n                            <option value=\"ENT\/Otorhinolaryngologist\">ENT\/Otorhinolaryngologist<\/option>\n                            <option value=\"Gastroenterology\">Gastroenterology<\/option>\n                            <option value=\"General Practice\/Family\">General Practice\/Family<\/option>\n                            <option value=\"Genetics\">Genetics<\/option>\n                            <option value=\"Hearing and Speech\">Hearing and Speech<\/option>\n                            <option value=\"Internal Medicine\">Internal Medicine<\/option>\n                            <option value=\"Neonatology\">Neonatology<\/option>\n                            <option value=\"Neurology\">Neurology<\/option>\n                            <option value=\"Nutrition, Metabolic\">Nutrition, Metabolic<\/option>\n                            <option value=\"Obstetrics\">Obstetrics<\/option>\n                            <option value=\"Orthopedics\">Orthopedics<\/option>\n                            <option value=\"Pediatric Endocrinology\">Pediatric Endocrinology<\/option>\n                            <option value=\"Pediatric Endocrinology, Diabetes &amp; Metabolism\">Pediatric Endocrinology, Diabetes &amp; Metabolism<\/option>\n                            <option value=\"Pediatric ENT\">Pediatric ENT<\/option>\n                            <option value=\"Pediatric Gastroenterology\">Pediatric Gastroenterology<\/option>\n                            <option value=\"Pediatric Gastroenterology &amp; Metabolism\">Pediatric Gastroenterology &amp; Metabolism<\/option>\n                            <option value=\"Pediatric Genetics\">Pediatric Genetics<\/option>\n                            <option value=\"Pediatric Metabolism\">Pediatric Metabolism<\/option>\n                            <option value=\"Pediatric Neurology\">Pediatric Neurology<\/option>\n                            <option value=\"Pediatric Neurosurgery\">Pediatric Neurosurgery<\/option>\n                            <option value=\"Pediatric Orthopedics\">Pediatric Orthopedics<\/option>\n                            <option value=\"Pediatric Radiology\">Pediatric Radiology<\/option>\n                            <option value=\"Pediatrics\">Pediatrics<\/option>\n                            <option value=\"Primary Care\">Primary Care<\/option>\n                            <option value=\"Psychology \/ Psychiatry\">Psychology \/ Psychiatry<\/option>\n                            <option value=\"Pulmonology\">Pulmonology<\/option>\n                            <option value=\"Radiology (MRI imaging)\">Radiology (MRI imaging)<\/option>\n                            <option value=\"Research\">Research<\/option>\n                            <option value=\"Social Worker\">Social Worker<\/option>\n                            <option value=\"Surgery\">Surgery<\/option>\n                        <\/select>\n                    <\/div>\n\n                    <div class=\"form-item\">\n                        <label for=\"professional-designation\">Professional designation<span class=\"required\">*<\/span><\/label>\n                        <select class=\"text\" id=\"professional-designation\" required\n                        data-pristine-required-message=\"Please select your professional designation\">\n                            <option value=\"\">Select your professional designation<\/option>\n                            <option value=\"DO\">DO<\/option>\n                            <option value=\"MA\">MA<\/option>\n                            <option value=\"MD\">MD<\/option>\n                            <option value=\"NP\">NP<\/option>\n                            <option value=\"PA\">PA<\/option>\n                            <option value=\"Pharmacist\">Pharmacist<\/option>\n                            <option value=\"PhD\">PhD<\/option>\n                            <option value=\"RN\">RN<\/option>\n                            <option value=\"Other\">Other<\/option>\n                        <\/select>\n                    <\/div>              \n\n                    <div class=\"form-item\">\n                        <label for=\"hospital-clinic-affiliation\">Practice name<span class=\"required\">*<\/span><\/label>\n                        <input class=\"text\" id=\"hospital-clinic-affiliation\" type=\"text\" required\n                        data-pristine-required-message=\"Please enter your practice name\">\n                    <\/div>\n\n                    <div class=\"form-item\">\n                        <label for=\"phone-number\">Phone<\/label>\n                        <input class=\"text\" id=\"phone-number\" type=\"text\"\n                        data-pristine-required-message=\"Please enter your phone number\"\n                        data-pristine-pattern-message=\"Please enter a valid phone number\"\n                        data-pristine-pattern=\"\/^\\(?([0-9]{3})\\)?[-. ]?([0-9]{3})[-. ]?([0-9]{4})$\/\">\n                    <\/div>\n\n                    <div class=\"form-item check-item\">\n                        <input type=\"checkbox\" id=\"rep-contact-me\" name=\"rep_contact_me\">\n                        <label for=\"rep-contact-me\">I\u2019d like a BioMarin representative to contact me.<br><small>A representative will reach out to you shortly.<\/small><\/label>\n                    <\/div>\n\n                    <div class=\"form-item check-item\">\n                        <input type=\"checkbox\" id=\"accept-ts-cs\" name=\"accept_ts_cs\" required\n                        data-pristine-required-message=\"Please agree to the terms of use\">\n                        <label for=\"accept-ts-cs\"><strong>I agree to the Terms of Use.<\/strong><span class=\"required\">*<\/span><br>By checking the box to the left and clicking &ldquo;Submit&rdquo; below, I confirm I am at least 18 years old; and confirm I agree to BioMarin\u2019s <a href=\"https:\/\/www.biomarin.com\/data-privacy-center\/\" target=\"_blank\">Privacy Policy and CCPA Notice<\/a> and <a href=\"https:\/\/medinfoterms.com\/\" target=\"_blank\">Terms of Use<\/a>; consent to BioMarin, its successors, agents, and\/or assigns using the email address I have provided to keep me informed about updates about news and developments about VOXZOGO; and confirm I understand these communications\/materials may contain information that markets or advertises BioMarin products, goods, or services.<\/label>\n                    <\/div>\n\n                    <div class=\"form-item\">\n                        <input type=\"submit\" class=\"button\" value=\"Submit\">\n                    <\/div>\n                <\/form>\n                <form id=\"mktoForm_3470\" style=\"display:none;\"><\/form>\n            <\/div>\n\n            <div class=\"block form-success-confirmation\" style=\"display:none;\">\n                                    <h3>Thank you!<\/h3>\n<p>We&#8217;ll be in touch soon with additional information.<\/p>\n                                            <\/div>\n        <\/div>\n    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