Sample request fax form

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.
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