Get Samples

This guide provides clear, step-by-step instructions on how to accurately complete the Samples request form for ®. By following these guidelines, you can ensure your request is processed smoothly and efficiently.

Follow the steps to complete your Samples request form

1. Click the ‘Get Form’ button to obtain the Samples request form and open it for further editing.
2. Enter your practitioner name in the designated field. Make sure to include all relevant titles to accurately reflect your qualifications.
3. In the 'Professional designation' section, circle the appropriate designation (MD, DO, NP, PA) that corresponds to your qualifications.
4. Fill in your phone number, ensuring that it is up-to-date so that you can be contacted if necessary.
5. Provide your fax number. This is essential for receiving the samples, so be sure it is correct.
6. Complete the address section, ensuring you provide your office address. Remember, samples cannot be sent to a P.O. box.
7. Specify the city, state, and ZIP code corresponding to your office address.
8. In the 'Product request' section, check the box for the type of samples you are requesting (5 Patient Sample Packs or 5 1x7 Cards).
9. Review the product description for the selected samples and confirm that they meet your needs.
10. Sign and date the form at the bottom to certify your request. Make sure to provide your state license number and its expiration date.
11. Once the form is completed, fax it along with a copy of your state license to the given fax number to process your sample request.
12. After faxing, keep a copy of the form for your records. Ensure that you have submitted the request correctly to avoid any delays.

Complete your Samples request online today to ensure your patients receive the support they need.