SST FREE SAMPLE - PRE-REQUEST FORM
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SST FREE SAMPLE - PRE-REQUEST FORM
PHYSICIAN`s EMAIL
Important: Enter a valid e-mail address. Receipts will be sent to this address.
*E-Mail:
Shipping Information
*Physician`s First Name
Middle Initial:
*Physician`s Last Name:
*Address Line 1:Where free sample is delivered
Address Line 2:Apt. or Suite No.
*City:
*State:
*Zip Code:
REGULATORY INFORMATION
*NAME OF PRACTICE
*FULL CONTACT NAME
*STATE LICENSE #
COUPON CODE:
*REQUEST DATE
ORDER FOR FREE SAMPLE BOX SST 10 LOZENGES
Submission of the present form certifies that I am a licensed practitioner in the State listed above. I understand that the sample products I have requested cannot be sold, bartered or returned for credit. Final form will be delivered to me by Email for signing and faxing to (201) 552-2289 in order to receive one set of 6 box of SST Lozenges 10.
REQUEST PRODUCT SAMPLES:
SST Lozenges - ONE PACK 6 BOX OF 10 UNITS
ONLY XEROSTOMIA DOCUMENTATION
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