Get Sample Request Form

Filling out the Sample Request Form online can be a straightforward process. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete your Sample Request Form.

1. Click ‘Get Form’ button to obtain the Sample Request Form and open it in your preferred document viewer.
2. Complete the following personal information sections: Practitioner First Name, Practitioner Last Name, and Professional Designation. Ensure that this information is accurate to facilitate proper processing.
3. Fill in your Street Address, Suite Number (if applicable), City, State, Zip Code, and Office Phone Number accurately. This is necessary for the delivery of the sample.
4. Provide your State License Number, Office Contact Name, Office Email Address, and Office Fax Number in the designated fields to confirm your identity and practice.
5. In the Product Description section, indicate the specific products you are requesting, including Size and Quantity. Ensure to specify the correct product codes, such as 55494-100-99, as required.
6. Sign your name and include the date of request where indicated at the bottom of the form. Note that your original signature is essential and cannot be replaced by a signature stamp or a designee’s signature.
7. Before finalizing your request, verify that all required fields are complete. Missing information will result in the request not being processed.
8. Fax the completed form to 973-644-2386, ensuring that you do not include a cover sheet unless specified.
9. After faxing the form, it's advisable to follow up to confirm receipt and ensure that your sample request is being processed.

Start completing your Sample Request Form online to obtain the necessary samples for your practice.