Get Sample Request Form

Completing the Sample Request Form online is a straightforward process designed to ensure you receive the necessary samples efficiently. This guide provides detailed, step-by-step instructions to assist you in accurately filling out the form.

Follow the steps to complete the Sample Request Form:

1. Click the ‘Get Form’ button to access the Sample Request Form and open it in your preferred online editor.
2. Enter your first name in the designated field marked with an asterisk (*). This information is required.
3. Fill in your last name in the field provided, also marked with an asterisk (*). This field is mandatory.
4. Input your practice name in the appropriate section. This field is optional.
5. Provide your address in the specified field, noting that shipments cannot be sent to P.O. Box addresses. This field is required.
6. Enter your city in the field provided, which is a required section.
7. Select your state from the dropdown menu, ensuring accuracy in this required field.
8. Input your phone number to ensure contactability. This information is required.
9. Include your fax number in the optional field.
10. Enter your zip code in the required field.
11. Provide your email address in the designated section, which is required for communication regarding your request.
12. Select the items you wish to receive by checking the appropriate boxes: ® 3-mg Tablets, ® 6-mg Tablets, or ® Vouchers.
13. Confirm your eligibility to receive these samples by answering the questions about treating patients for schizophrenia or schizoaffective disorder.
14. Sign the form in the designated sign section and provide the date of your signature. Make sure to not use signature stamps as they are not authorized.
15. Review all entered information for accuracy and completeness. Ensure all required fields marked with an asterisk (*) are filled.
16. Save the changes made to the form. You may also choose to download, print, or share the form as needed.

Complete your Sample Request Form online now to receive your ® samples efficiently.