Get Sample Request - Allergan

This guide provides a clear and professional approach to completing the Sample Request - Allergan form. By following these steps, you will be able to successfully fill out the online request for complimentary drug samples offered by Allergan.

Follow the steps to complete your request form

1. Press the ‘Get Form’ button to obtain the Sample Request - Allergan form and open it in your chosen editor.
2. Begin by completing the practitioner name field with your full name. Ensure that the name provided matches your professional designation.
3. In the professional designation section, circle the appropriate designation that applies to you, such as MD, DO, NP, or PA.
4. Enter your phone number in the designated field for easy contact.
5. Input your fax number where you would like to receive confirmations or additional information regarding your request.
6. Fill in your office address accurately. Note that samples cannot be sent to a P.O. Box; only physical office addresses are acceptable.
7. List your city, state, and ZIP code to ensure proper delivery of the samples.
8. Indicate the product request by selecting the number of bottles you desire. For instance, you may choose 3 bottles.
9. Specify any additional resources you are requesting, such as a package of patient savings cards.
10. Provide the product and resource descriptions as requested. Describe the product as 'BYVALSON ( and ) 5 mg/80 mg tablets' and the resource as 'BYVALSON Patient Savings Card and Holder'.
11. Include the NDC code, which is 'NDC 0023-5874-07', to assist in the processing of your order.
12. Sign the form to certify that you are a licensed practitioner and agree to the terms outlined regarding the receipt and use of drug samples.
13. Fill in your state license number and the expiration date to confirm your licensing status.
14. Once all fields are completed, review your form for any errors or missing information.
15. Save your changes, and you may choose to download, print, or share the completed form as needed.

Complete your Sample Request - Allergan form online today for your drug samples!