SAMPLE REQUEST PLEASE PRINT CLEARLY

SAMPLE REQUEST
FAX: (908) 927-1926
PLEASE PRINT CLEARLY
MAIL:
COMPLETE ALL INFORMATION
Practitioner’s signature, professional designation, address
and Medical License Number is required.
Valeant Pharmaceuticals North America
Attn: Customer Service
700 Route 202/206, Bridgewater, NJ 08807
(908) 927-1926
FAX:
EMAIL: pharmcs@valeant.com
(Incomplete requests will not be filled)
For Customer Service inquiries please call (800) 321-4576
SHIP SAMPLE TO:
Practitioner’s Name and Professional Designation
State Medical License Number (required)
Practice Name
Telephone Number
Street Address
e-mail address
City, State and Zip Code
* PLEASE SEND THE LACRISERT ® SAMPLE FOR USE IN MY
PRACTICE FOR THE MEDICAL NEEDS OF MY PATIENTS.
* I CERTIFY THAT I AM AUTHORIZED AS A LICENSED
PRACTITIONER TO RECEIVE THESE PRODUCTS.
* I UNDERSTAND THAT MY SIGNATURE WILL BE REQUIRED AS
VERIFICATION OF RECEIPT UPON DELIVERY.
X
Product Requested:
Quantity
Requested:
(NDC 25010-805-08) Lacrisert ®
5mg 10 Inserts per pack
Limit of five sample packs per customer.
All samples must be used within sampling guidelines
(CFR, Title 21, Part 203.30 subpart D)
Practitioner Signature (required)
X
Manufacturer:
Date Requested
=== FOR OFFICE USE ONLY === Program Type: WEB
Order number:
Date Order Sent: