1. technology and computing
2. hardware
3. computer peripherals
4. printers, copiers and fax
5. fax machines

SAMPLE REQUEST FAX FORM
ENABLEX® Sample Order Fulfillment
Fax #: 1-855-812-7820
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
Professional Designation
MD
DO
PA
NP
(Circle)
Specialty
Phone Number
Fax Number
Email
Address
(Samples will not be issued or delivered to a PO box; please provide your office street address.)
City
State
Sample Product Request
(Check one or both)
❑❑ NDC 0430-0170-96
❑❑ NDC 0430-0171-96
Zip
Product Description
Quantity
ENABLEX® 7.5 mg per tablet x 7 tablets
8 bottles
ENABLEX® 15 mg per tablet x 7 tablets
8 bottles
ENABLEX® 7.5 mg NDC 0430-0170-96 Manufacturer: Warner Chilcott Deutschland GmbH
ENABLEX® 15 mg NDC 0430-0171-96 Manufacturer: Warner Chilcott Deutschland GmbH
Authorized Sample Distributor: J. Knipper and Company, Inc.
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, prescribe, and dispense these drug samples. I certify that I have requested these samples for 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 I am a Nurse Practitioner or Physician Assistant, I certify I am authorized and eligible, in the state in which I am now practicing, to request and
receive these samples and that I have my supervising Physician’s approval to do so.
If my state requires a collaborative agreement with a supervising physician, I certify that this agreement is in good standing.
Practitioner/Physician Signature
Date
(Authorized practitioner signature–no stamped signatures allowed)
State License Number
Exp. Date
By submitting this sample request form, I agree that the information I am providing may be used by Actavis, its affiliates or
vendors to keep me informed via email about new products, services, special offers, or other opportunities that may be of
interest to me, as they become available. This information will be used in accordance with the Actavis Privacy Policy, available
at http://www.actavis.com/privacy. I can stop Actavis from sending me future ENABLEX®-related communications by clicking
on the “unsubscribe” link which will be available in future emails. If, after I opt out of receiving future ENABLEX®-related
communications, I use this form to request additional ENABLEX® samples, I will remain unsubscribed.
Any recipient of this form via fax may request that Actavis not send any future advertisements to this or other specified telephone facsimile machines.
To make such request, please call 1-877-629-3912 or fax the request to 1-855-812-7820.
Your request must identify the telephone number of each facsimile machine to which the request relates. Your request will no longer be valid if, after
your request is made, you provide express invitation or consent to Actavis to send advertisements to you at the identified facsimile numbers.
Any failure to honor your request within 30 days is unlawful.
ENABLEX® is a registered trademark of Warner Chilcott Company, LLC.
© 2014 Actavis Pharma, Inc., Parsippany, NJ 07054. All rights reserved. 11027 8/14
Web1