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N. In order to expedite your sample request, please complete the information below and fax to the number listed above. Incomplete requests will not be processed. Shipping is via UPS. Please allow 5 10 business days for delivery. For any product-related questions concerning or HCT, please call 1-877-HYPER-10 (1-877-497-3710). MD c DO c NP c PA c Practitioner s Last Name, First Name State License Number Expiration Date ME Number Print the STATE LICENSE NUM.

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How to fill out the Sample Request Form online

Filling out the Sample Request Form is an important step for licensed practitioners who wish to request medication samples. This guide will walk you through each section of the form to ensure your request is complete and processed promptly.

Follow the steps to successfully complete your request.

  1. Click the ‘Get Form’ button to access the Sample Request Form and open it in your preferred online platform.
  2. Enter the practitioner’s last name and first name in the designated fields at the top of the form.
  3. Provide your state license number as exactly displayed on your certificate in the appropriate section.
  4. Fill in the expiration date of your license, ensuring that the information is accurate.
  5. Input your ME number in the corresponding field.
  6. Complete the address section with the physical address of your practice, noting that P.O. Boxes are not acceptable.
  7. Fill in the city, state, and ZIP code accurately to prevent any delivery issues.
  8. Provide your phone number and fax number in the required fields.
  9. Select the quantity and type of or HCT samples you wish to receive by checking the appropriate boxes.
  10. Sign the form in the designated area with an original ink signature, as signature stamps are not accepted.
  11. Include the date of your signature next to your signature.
  12. After completing all sections of the form, review it for completeness, as incomplete forms cannot be processed.
  13. Once verified, you can fax the completed form to the number listed at the top of the document.

Complete your Sample Request Form online today to ensure your samples are delivered quickly and efficiently.

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To make a requisition form, start by determining what information you need to collect. You can use a template or blank document in pdfFiller, and then add fields for details like item description, quantity, and approval signatures. By creating a requisition form with pdfFiller, you streamline the process and ensure that all necessary information is captured efficiently.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232