Download Sample Request Fax Form
To request a pharmaceutical sales representative to visit your office, please fill out the following form.
Your Contact Information
Your Name (required):
Your Email (required):
If you are requesting samples, please provide your State License Number
State License Number (required):
Phone Number (required):
Business Address (required):
City and State (required):
So we can direct your request to the appropriate person, please provide the zip code where you would like samples or literature shipped to.
ZIP Code (required):
Please enter the 4 random characters below to verify you a real person
In order to comply with the FDA regulations when requesting samples, a fax order form will be sent to you for your signature. Please sign the fax order form and return it to the fax number listed. Thank you!
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Metanx® is a medical food for use under medical supervision.