Nutricia ONS Sample Service

Nutricia ONS Sample Service
This form can be used to request Nutricia product samples to be delivered to your patient’s home.
Please tick the relevant box to ensure your patient receives the appropriate sample for them (max. 2).
Fortisip Compact Protein Starter Pack
Fortisip Compact Starter Pack
Mixed flavours (4 x 125ml bottles)
Mixed flavours (6 x 125ml bottles)
code – 72266

code – 88425

Fortisip Compact Fibre Starter Pack
Fortijuce Starter Pack
Mixed flavours (4 x 125ml bottles)
Mixed flavours (4 x 200ml bottles)
code – 60388

code – 29479

Forticreme Complete Starter Pack
Complan Shake Starter pack
Mixed flavours (4 x 125g pot)
(5 x mixed flavours + shaker)
code – 19707

code – 56745

Calogen Extra Shots
Scandishake Mix Starter pack
Strawberry flavour (6 x 40ml shots)
(6 x mixed flavour sample pack)
code – 32671

code – 64550

Neutral flavour (6 x 40ml shots)
code – 55466

Healthcare Professional Details
Patient Details
Name
…………………………………………
Name
…………………………………………
Work Address
…………………………………………
Work Address
…………………………………………
…………………………………………
…………………………………………
Post Code
…………………………………………
…………………………………………
Email Address
…………………………………………
Post Code
…………………………………………
Telephone No.
…………………………………………
Telephone No.
…………………………………………
Privacy Statement: We are engaged in respecting your private life and protecting the information you submit. Nutricia
complies fully with the Data Protection Act 1998. This information will be used solely for the purpose of providing the
service requires and will not be used for marketing purposes.
Please fax the completed form to 0845 450 2422.
Alternatively, you can also email [email protected] or post the form to Nutricia Sample Supply Service, 1 Swift
Way, Bowerhill Industrial Estate, MELKSHAM, Wiltshire SN12 6GX.
Fax receipt confirmation is available on Tel: 0845 450 2420
Form valid until 31st December 2014. A new form will be issued prior to this date. Orders submitted after this date will
not be processed. If you do not receive your samples within 3 working days of faxing this form, please send an email
with the delivery postcode to [email protected] .