This form is to request samples for your office to pass out .

 Dermatology Allergy General Practice Internal Medicine OBGYN Other

 Email Phone Fax

 To be used for doctors and staff To be used to hand out to patients

If you are going to pass out samples to patients they are going to want to know where to purchase it.

 Yes No

If no, which pharmacy/drug store(s) would be most convenient for your patients to purchase it at?.

We will contact these pharmacies and when they order we will notify you so you can tell your patients where to purchase
it locally.