FAX #: 1-877-801-9949 Your shipment of professional samples may only be sent to your office address. PLEASE NOTE: In compliance with the Prescription Drug Marketing Act regulations, incomplete request forms cannot be processed and samples will not be forwarded. PRACTITIONER NAME PHONE # FAX # STREET ADDRESS (Samples will not be issued or delivered to a PO Box; please provide your office street address) CITY STATE ZIP EMAIL q q Yes, please send 6 boxes of (NDC 0430-042.
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How to fill out the Generesscom Form online
Filling out the Generesscom Form online is a straightforward process. This guide will provide you with step-by-step instructions to ensure that your form is completed accurately and submitted without delay.
Follow the steps to complete the Generesscom Form efficiently.
- Press the ‘Get Form’ button to access the Generesscom Form. This action will enable you to open the form in your preferred editing platform.
- Enter your practitioner's name in the designated field. Ensure that the name you provide matches your state license.
- Fill in your professional phone number. This contact information is crucial for any follow-up regarding your request.
- Input your fax number in the fax section. This is where your completed form will be sent.
- Provide your street address. Remember, samples will only be sent to your office street address; PO Box addresses are not accepted.
- Complete the city, state, and ZIP code fields accurately.
- Enter your email address to receive updates about your order.
- Indicate the number of boxes you wish to request by checking the appropriate box: typically six boxes of Lo ® Fe.
- Select your professional designation from the options provided, ensuring it reflects your current licensure.
- Sign the form to certify that you are legally authorized to request the drug samples and agree to the terms outlined.
- Include your state license number and its expiration date.
- Review the completed form for any errors or omissions before submitting.
- Once confirmed, print the form, sign it where indicated, and fax it to the designated number: 1-877-801-9949.
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