Get Samples

Filling out the Samples request form is a simple process that can be completed online. This guide will walk you through each step to ensure your submission is accurate and complete.

Follow the steps to successfully submit your request.

1. Click the ‘Get Form’ button to access the Samples request form and open it in your preferred editing tool.
2. Begin by entering your practitioner name in the designated field. Ensure that it is spelled correctly as this will be part of your identification.
3. Select your professional designation by circling one of the options: MD, DO, NP, or PA. This step is crucial for validating your request.
4. Provide your phone number and fax number in the respective fields, allowing for easy communication regarding your request.
5. Fill in your office address accurately, including city, state, and ZIP code. Note that samples will not be delivered to a PO Box; an office address is required.
6. Indicate the product request by noting how many boxes of Minastrin® 24 Fe you would like to receive. Ensure the quantity is correct.
7. Complete the resource request section if you wish to request patient brochures or savings cards. State the order quantity for each resource requested.
8. Review the certification statement, ensuring you understand and agree to the terms. You must sign and date the form, along with entering your state license number and its expiration date.
9. Once all fields are completed, review the form for accuracy and completeness. Save your changes.
10. Print the completed form and fax it to the number provided: 1.866.765.7098, along with a copy of your state license.

Complete your Samples request online today to ensure timely delivery of your professional samples.