Get Sample Request Form -

Filling out the Sample Request Form online is a straightforward process that allows licensed practitioners to request drug samples for their patients. This guide provides detailed instructions to ensure you complete each section accurately and efficiently.

Follow the steps to correctly complete the Sample Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the physician's name in the designated field to identify the requester.
3. Enter the address including the street, city, state, and zip code. Ensure all information is current and complete for proper processing.
4. Provide the telephone and fax number, along with an email address to assist in communication regarding your request.
5. Input your DEA number and state license number, including the expiration date. This information verifies your eligibility to request drug samples.
6. Read and confirm the certification statement that declares you are a licensed practitioner and specify the samples are for medical purposes only.
7. Affix your signature and date in the appropriate fields to validate your request.
8. Specify the identity of the drug sample requested, ensuring you indicate the correct quantity and specifics.
9. Once all fields are complete, proceed to save any changes you've made. You may choose to download, print, or share the form as needed.

Complete your document online today to ensure timely processing of your sample request.