Get Vraylar Sample Request Form

Filling out the Vraylar Sample Request Form online is a straightforward process that enables healthcare practitioners to request complimentary samples of Vraylar (cariprazine) for their patients. This guide will provide step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete your request form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Provide your professional designation by circling one of the options: MD, DO, NP, or PA. This indicates your qualifications and role as a practitioner.
3. Enter your phone number and fax number in the appropriate fields. Ensure that these numbers are accurate for communication regarding your request.
4. Fill in your office address, including city, state, and zip code. Note that samples cannot be sent to a P.O. Box; a physical office address is required.
5. In the product request section, choose the product you would like to receive by checking the box next to your preferred option: 1.5 mg capsules, 3 mg capsules, or Mixed Blister Pack.
6. Certify your request by signing the form. Your signature indicates that you are a licensed practitioner authorized to request these samples and that you are doing so for legitimate medical purposes.
7. Include your state license number and its expiration date to confirm your qualifications.
8. After completing the form, review it for accuracy. Once confirmed, you can save your changes, download a copy for your records, print it out, or share it as required.

Start completing your Vraylar Sample Request Form online today to ensure timely receipt of your samples.