Off-Label Indication Request Form

All requests for Elsevier to review off-label indications must be submitted by fully completing the form
below. Please submit only 1(one) off-label indication per form. All requests will be reviewed per Elsevier’s
Editorial Policy. Any content changes will be made at the discretion of Elsevier’s Clinical Editorial Team,
and may result in no change or in a change that differs from the original request. Evidence from
published randomized controlled studies is preferred; although information with high clinical significance
(i.e., practice changing) from unpublished sources (e.g., abstracts, poster presentations, etc.) may be
considered.

All requests will be retained for no less than 5 years and viewing may be requested as per Elsevier’s
Editorial Policy.

Company Name:
Required

Contact Name:*
Required

Contact Telephone Number:*

Required

Contact Email:*
Required

Date of Submission:

Brief summary of the specific

off-label request (no more than 1 or
2 sentences):

Expanded summary of the change

request including rationale for the
proposed change
(no more than 3 to 5 paragraphs):

Literature supporting the request

(electronic copies should be
attached for all items in the
reference list):

Please submit to Kay Morgan/Michelle McLeod by email at productinfo@goldstandard.com

or by fax 813-579-2786.

* This information is for Elsevier use only and will not be published to our customers.