Get Samples

Sample Request Fax Form To receive your complimentary samples of vilazodone HCl complete this form and fax it along with a copy of your state license to Sample Order Fulfillment Fax 1-866-765-7098 Your shipment of professional samples may only be sent to your office address. Allergan reserves the right to decline requests for samples from practitioners whose medical practice and/or patient population is deemed inconsistent with the approved product indication s Practitioner/Physician signature Date State license number Expiration date Please see full Prescribing Information including Boxed Warning available at www. viibrydhcp.com. 2016 Allergan. All rights reserved. Allergan and its design are trademarks of Allergan Inc. and its design are registered trademarks of Forest Laboratories LLC an Allergan affiliate. Please note In compliance with the Prescription Drug Marketing Act regulations incomplete request forms cannot be processed and samples will not be forwarded* MD DO NP PA Practitioner name Professional designation Circle one Phone number Fax number Address Samples will not be issued or delivered to a PO box please provide your office address. City State Product request 5 Patient Sample Packs ZIP code Product description NDC 2-week Patient Sample Pack each pack includes seven 10 mg tablets and seven 20 mg tablets NDC 0456-1101-14 Manufacturer Patheon Puerto Rico Inc* Authorized sample distributor Anda Inc* By signing this form I request the drug samples listed herein and certify that I am a licensed practitioner currently authorized under applicable federal and state law to request receive and dispense these drug samples. I also certify that I have requested these samples for the legitimate medical needs of my patients. I understand that the sale or offer to sell a drug sample is a federal offense. I certify that I will not seek payment from any patient or third-party payor for these drug samples and I will not sell resell trade barter return for credit or seek reimbursement for any drug sample. Allergan reserves the right to decline requests for samples from practitioners whose medical practice and/or patient population is deemed inconsistent with the approved product indication s Practitioner/Physician signature Date State license number Expiration date Please see full Prescribing Information including Boxed Warning available at www. viibrydhcp*com* 2016 Allergan* All rights reserved* Allergan and its design are trademarks of Allergan Inc* and its design are registered trademarks of Forest Laboratories LLC an Allergan affiliate. Please note In compliance with the Prescription Drug Marketing Act regulations incomplete request forms cannot be processed and samples will not be forwarded* MD DO NP PA Practitioner name Professional designation Circle one Phone number Fax number Address Samples will not be issued or delivered to a PO box please provide your office address. City State Product request 5 Patient Sample Packs ZIP code Product description NDC 2-week Patient Sample Pack each pack includes seven 10 mg tablets and seven 20 mg tablets NDC 0456-1101-14 Manufacturer Patheon Puerto Rico Inc* Authorized sample distributor Anda Inc* By signing this form I request the drug samples listed herein and certify that I am a licensed practitioner currently authorized under applicable federal and state law to request receive and dispense these drug samples.