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] .