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Sample Basic Survey

Whether you are considering treatment or you are already on FARXIGA® (dapagliflozin), we're here to help. Just fill out the form below and we'll send you important information that may help you throughout your journey.

If you're considering FARXIGA, you'll receive a FREE Information Kit, including a discussion guide, that can help you and your doctor decide if FARXIGA is right for you.

If you're about to start or are already taking FARXIGA, you'll receive: savings on FARXIGA,* ongoing information and support, and prescription coverage support.

*Savings subject to monthly limit. Subject to eligibility. Restrictions apply.Subject to eligibility. Restrictions apply. Not available for government-insured patients.

It's FREE, so sign up today or call us toll-free at 1-855-3FARXIGA (1-855-332-7944).

By completing the registration, you may also receive ongoing information and support related to your condition, including treatment information.

AstraZeneca respects your personal health information. The information you provide may be used to send you health-related materials and to develop products, services, and programs. AstraZeneca, or third parties working on our behalf, will not sell or rent personal health information. If, in the future, you no longer want to receive health-related materials, call 1-800-236-9933. Please visit to review our Privacy Notice.


*Indicates required field.


By providing your date of birth, you verify
that you are at least 18 years of age.

 Considering this medication?
 About to start taking this medication?
 Currently taking this medication?
 Yes, I would also like to receive information in the future about all AstraZeneca products, programs, and services that may be of interest to me.
 Yes, I would be willing to be contacted on occasion to participate in market research studies sponsored by AstraZeneca.
 Yes, I would be willing to share my experience as a patient taking FARXIGA with an AstraZeneca representative.