Get Dialyvite Renal Multi-vitamins Rx & Otc Sample ... - Dialyvite.net

This guide provides a comprehensive overview of how to accurately fill out the Dialyvite Renal Multi-vitamins Rx & OTC Sample Request form. Whether you are new to this process or need a refresher, this step-by-step instruction will help ensure that your request is complete and submitted correctly.

Follow the steps to successfully complete your request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by checking the appropriate boxes for the Rx Samples you are requesting. Options include Dialyvite® Rx (1 mg folic acid), Dialyvite® Rx with Zinc (50 mg zinc), Dialyvite® 3000 Rx (3 mg folic acid), Dialyvite® 5000 RX (5 mg folic acid), and Dialyvite® Supreme D Rx.
3. Fill in the number of Rx script pads requested in the space provided. Indicate how many sheets per pad you require.
4. Provide the name of the physician or nurse practitioner requesting the samples, ensuring to print it clearly.
5. Enter the state license number and expiration date, which are both required for RX samples.
6. Sign and date the form to certify that the request is for the medical needs of your patients and that your state license is valid.
7. Include the facility's name, contact person's name, title, address, city, state, zip code, facility phone number, fax number, and email address.
8. Specify the quantity of patient education brochures and non-prescription order forms needed, indicating the number for both English and Spanish.
9. For non-prescription samples requested (OTC), check the boxes for any of the Dialyvite® products you would like to request, such as Dialyvite 800 or Dialyvite® Chewable Probiotic.
10. Finally, review all entries for accuracy, then save your changes, download, print, and share the form as needed, including faxing your request.

Complete your Dialyvite Renal Multi-vitamins Rx & OTC Sample Request online today!