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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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