Sample request fax form To receive your samples of Lo Loestrin® Fe, complete this form and fax it, along with a copy of your state license, to: Actavis Oral Contraceptive Sample Order Fulfillment FAX #: 1-877-801-9949 Your shipment of professional samples may only be sent to your office address. PLEASE NOTE: In compliance with the Prescription Drug Marketing Act regulations, incomplete request forms cannot be processed and samples will not be forwarded. PRACTITIONER NAME PHONE # FAX # STREET ADDRESS (Samples will not be issued or delivered to a PO Box; please provide your office street address) CITY STATEZIP EMAIL q q Yes, please send 6 boxes of Lo Loestrin® Fe (NDC 0430-0420-95) Actavis oral contraceptive products Manufactured by: Warner Chilcott Company, LLC, Fajardo, PR Distributed by: Actavis Pharma, Inc. (Each box contains a 1-month supply) PROFESSIONAL DESIGNATION (Select one): Yes, I would like to receive updates about q MD q DO q NP q PA By signing this form I request the drug samples listed herein and certify that I am a licensed practitioner currently authorized under applicable federal and state law to request, receive, and dispense these drug samples. I also certify that I have requested these samples for the legitimate medical needs of my patients. I understand that the sale or offer to sell a drug sample is a federal offense. I certify that I will not seek payment from any patient or third-party payor for these drug samples and I will not sell, resell, trade, barter, return for credit, or seek reimbursement for any drug sample. If my state requires a collaborative agreement with a supervising physician, I certify that this agreement is in good standing. AUTHORIZED PRACTITIONER/PHYSICIAN SIGNATURE DATE STATE LICENSE #/Exp Date (Original signature required—no stamps allowed) Print, sign your name above, and fax this form to 1-877-801-9949. Lo Loestrin® is a registered trademark of Warner Chilcott Company, LLC. Please see Selected Safety Information and Full Prescribing Information for Lo Loestrin® Fe, including Boxed Warning, available at www.loloestrin.com. © 2014, Actavis Pharma, Inc. Parsippany, NJ 07054 All rights reserved. 10677 4/14