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Create New Account

This portal is intended for healthcare providers with an active medical license. If you are a patient, please contact your healthcare provider.

Please fill out the necessary information below to create an account for this Portal.

(*) indicates required fields.



Express Consent Collection Statement

This site will allow you to establish a personalized account to perform activities. To create a personalized account, you must provide some personal data, including your name and email address. We will use the information you submit to maintain your account, to automatically complete other forms on the Site, and otherwise as described in our Privacy notice.

By clicking the I AGREE button and/or submitting your request, you acknowledge and agree to the following terms:

  • You are confirming that you have reviewed and agree and understand the Privacy notice, you consent to the collection and use of your personal data for the purposes of using this program or otherwise as consented.
  • You are confirming that you are a Healthcare Provider with a valid medical license.
  • No confidential relationship is established or implied by the company's acceptance or consideration of the submitted material.
  • I understand that I will NOT submit any patient’s personable identifiable information that includes, patient’s name, address, date of birth, initials, government issued identification numbers (e.g., social security numbers and national IDs), race or ethnicity, gender and sexual orientation.
  • I understand that I will NOT submit any Safety information on this portal.
  • I acknowledge that ViiV reserves the right to correct any administrative or technology-based errors which may occur during the request or review process.
  • By clicking the I AGREE button, you are consenting to the transfer and processing of your personal data to countries outside of your country of residence, specifically the United States of America, which may provide a different data protection rules than in your home country.
  • Otherwise, please refer to the Privacy notice section, “How to contact us” for direct contact information.
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