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Request for FREE Rx Patient Starter Samples
Complete this form and
fax to 866-909-8677
Please check box(es) of desired products or literature:
One box with 6 bottles (4 tablets per bottle) NDC# 42783-510-04
(Includes patient rebates and literature)
Patient Rebates and Literature ONLY
One bottle (10 mL) NDC# 42783-323-10
(Includes patient rebates and literature)
Patient Rebates and Literature ONLY
One box with 12 tubes (7.5 grams each) NDC# 42783-111-07
(Includes patient rebates and literature)
Patient Rebates and Literature ONLY
MD DO
DPM
PA
NP
Professional Designation
Name of Health Care Professional
Street Address (samples are not deliverable to PO Boxes)
City
State
Zip Code
State License Number
Expiration Date
X
Signature
Date
I certify that I am a licensed practitioner eligible to receive and prescribe these samples. If I am a Nurse Practitioner or
Physician Assistant, I certify that I am authorized and eligible in the state within which I am currently practicing to request
and receive these samples and that I have my supervising physician’s approval to do so. My signature on this request
certifies that I recognize that this is a product sample for the needs of my patients and will not be sold, traded, bartered or
returned for credit or for third-party reimbursement.
Specialists in the Science of Skin Care®
100 Fairway Drive, Suite 134 Vernon Hills, Illinois 60061
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847.362.8200
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www.eloracpharma.com
SFW Rev 051115