Get Request Bsamplesb -

Filling out the Request BSamplesb - form online is a straightforward process designed to help practitioners easily obtain complimentary samples of ®. This guide will provide clear, step-by-step instructions to ensure that the form is completed accurately and efficiently.

Follow the steps to fill out the Request BSamplesb - form online.

1. Click ‘Get Form’ button to access the Request BSamplesb - form and open it in your browser.
2. Begin by entering your practitioner name in the designated field to identify yourself.
3. In the professional designation section, circle the appropriate title that reflects your qualifications (MD, DO, NP, PA).
4. Provide your phone number to allow for any necessary communication regarding your request.
5. Fill in your fax number; this is the number where the samples will be sent.
6. Enter your office address where the samples will be shipped. Note that samples cannot be sent to a P.O. box.
7. Complete the city, state, and ZIP code fields alongside your office address.
8. Indicate the product request by checking the relevant box for either the 5 Patient Sample Packs or the 5 1x7 Cards options.
9. Sign the form to certify that you are a licensed practitioner authorized to request these samples for legitimate medical needs.
10. Enter the date of your signature.
11. Provide your state license number and its expiration date for verification purposes.
12. Once all sections are completed, save your changes and proceed to fax the form along with a copy of your state license to the designated fax number.

Complete your Request BSamplesb - form online to receive your samples promptly.