Follow the steps to complete your sample request form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Fill out the 'Deliver To' section with your first name, last name, complete address, and contact information including phone and fax numbers.
3. Enter your state license number in the designated field.
4. Check the appropriate box to confirm you are requesting the samples of ® ( Succinate) 2.5mg Tablets.
5. Affix your signature in the 'Practitioner Signature' field, ensuring no stamps are used.
6. Indicate your professional designation next to your signature.
7. Fill in the date when you are completing the form.
8. Review all the provided information for accuracy, and confirm your address before sending it.
9. Finally, fax the completed form without a cover sheet to the specified number: 1-800-233-9141.

Complete your sample request form online today to ensure timely delivery of necessary samples.