Get Sample Request Form Faxprc Comments 2.6.2018 Copy

Filling out the Sample Request Form FAXprc Comments 2.6.2018 Copy is a straightforward process. This guide will provide detailed instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. To start, locate and click the ‘Get Form’ button to obtain the Sample Request Form. This will allow you to access the form in the designated editor for completion.
2. Begin by entering the physician's first and last name in the appropriate fields. Ensure that the names are spelled correctly to avoid any issues in processing.
3. Next, input the state license number. Remember to avoid using abbreviations, as the full license number is required.
4. Select the professional designation by checking the applicable box next to MD, DO, NP, PA, or Other.
5. Complete the address section by entering Address 1, Address 2 (if applicable), city, state, zip code, and phone number.
6. Then, input the fax number where the completed form will be sent. Ensuring accuracy in this information is critical.
7. For the product description, specify '®' in the product field and enter the corresponding NDC code '64597-301-13'.
8. Indicate the size and quantity of the product requested, which is '20mg/10mg, 13 Capsules' with a quantity of '8'.
9. Review the signature section, which includes agreement statements regarding the use of the samples and licensure. Ensure to read this carefully before signing.
10. Finally, provide the licensed physician's signature, specialty, and the date in the specified format (mm/dd/yyyy) before proceeding to submit the completed form.
11. After ensuring all fields are filled correctly, you can save changes, download, print, or share the form as needed.

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