First Name* :
Middle Initial :
Last Name* :
Street Address* :
City* :
State* :	CHOOSE A STATE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip Code* :
E-Mail Address* :
Confirm E-Mail Address* :
Which are you currently taking?	DuetDHA Other:  I am not taking a prenatal vitamin
How far along are you in your pregnancy experience?	Trying to get pregnant First trimester Second trimester Third trimester Breastfeeding Other:
How did you learn about DuetDHA.com?	A friend An ad in a magazine Internet search My doctor The staff at my doctor’s office An ad on babyzone.com An ad on WhatToExpectWhenExpecting.com An ad on Conceive.com An email advertisement
Would you like to join in the DuetDHA Complete ® Community?*	Yes No
Would you like DuetDHA Complete® to send you an email reminder when it is time to get your fourth refill?*	Yes No
* Required Field

Disclaimer:
By completing this form, I understand that I am giving Xanodyne Pharmaceuticals Inc. (including those acting on Xanodyne's behalf) consent to use my personal information to provide me with information and offers relating to Xanodyne products.

Xanodyne does not rent, sell, or share personal information about you with other people or nonaffiliated companies. You may cancel your enrollment anytime by clicking here.

Any coupons received from Xanodyne or in association with the Duet^® DHA Community program are void where prohibited by law.

As with any prescription-strength product containing folic acid, omega-3 fatty acids, iron, or vitamins D and E, please adhere carefully to the recommended dosages. Folic acid may obscure the diagnosis of pernicious anemia. Supplementation with omega-3 fatty acids should be avoided in patients, including those taking anticoagulants, with inherited or acquired bleeding diatheses. Keep this and all iron containing products out of the reach of children.See full Prescribing Information for complete usage and safety data.

RDAs are established under the IOM and state the amount of a nutrient that is needed for most people (97.5%) to stay healthy. They are specific to the age and gender of the person, including pregnant and/or breast-feeding women. RDAs are supplemented with a tolerable upper intake level–the largest daily amount of a vitamin, mineral, or other nutrient consumed or taken that is unlikely to cause harm. Supplementation with DuetDHA Complete may require additional dietary intake of calcium, magnesium, and vitamin E to meet the RDAs for pregnancy.