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Get Sample Request Form 2019-2024

Duct Description Product Number 72384-752-01 72384-753-01 Professional Designation MD DO PA State NP Zip Office Fax Number Office Email Address Please Check Item(s) Requested: ® () 100MG 1CT, Tablets ® () 200MG 1CT, Tablets 6 Units 6 Units Quantity and frequency of orders may be limited due to availability and/or at the discretion of Metuchen Pharmaceuticals. Anticipated delivery time is 5 -10 business days. Instructions: To receive the sample product yo.

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