FAX: 1-877-619-5796 Your shipment of professional samples may only be sent to your office address. PLEASE NOTE: In compliance with the Prescription Drug Marketing Act regulations, incomplete request forms cannot be processed and samples will not be forwarded. PRACTITIONER NAME PHONE # FAX # STREET ADDRESS (Samples will not be issued or delivered to a PO Box; please provide your office street address) CITY STATE ZIP q Yes, please send (circle one) 12 bottles or 24 bottles of (.
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How to fill out the Samples Request Form online
Filling out the Samples Request Form online is a straightforward process that allows practitioners to request samples of ® () 8 mg capsules. This guide will help you navigate each section of the form efficiently and ensure that your request is processed without any issues.
Follow the steps to complete the Samples Request Form accurately.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Provide your practitioner name in the designated field. This should be your full legal name as recognized by your licensing authority.
- Enter your phone number, ensuring it is accurate and includes the area code for easy communication.
- Fill in the fax number where the completed form should be sent. Double-check this number for accuracy.
- In the street address section, input your office street address. Note that samples cannot be sent to a P.O. Box, so it is essential for this entry to be correct.
- Complete the city, state, and ZIP code fields with your office's location information.
- Select the quantity of ® samples you wish to receive by choosing either 12 or 24 bottles. Each bottle contains 7 capsules.
- Indicate your professional designation by selecting one of the available options: MD, DO, NP, or PA.
- Provide your original signature in the designated field to confirm your request. Note that stamped signatures are not acceptable.
- Enter the date of signing the form and your state license number along with its expiration date.
- Once all sections are completed, save the changes made to the form. You may then choose to fax the form to 1-877-619-5796, ensuring that all information is clearly readable.
Complete your Samples Request Form online today to ensure a smooth and efficient process for your sample requests.
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