Request Samples

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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):

Specialty:

If you are requesting samples, please provide your State License Number

State License Number (required):

Phone Number (required):

Fax Number:

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):

Additional Comments:

Please enter the 4 random characters below to verify you a real person
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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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