Attention: All practice sample requests must be completed by a licensed healthcare provider with a valid license number and shipped to a practice address. We will not ship practice samples to home addresses. Sample requests are uploaded to our warehouse and processed on a rolling schedule every 2 weeks and are then packed and shipped for their final destination.

Your Name*
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Your Phone*
Your Email*
Institution Name*
Institution Address
Street Address Address Line 2 City State ZIP Code
Area of Specialty
Patient Population
Patient Setting
Your Credential Type
Credential (NPI, License, or CDR)*
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Email
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Your Sample Kit will include one case of:

Refreshing Orange Flavor – 1 case of 12 bottles

AND

Original Vanilla Flavor – 1 case of 12 bottles

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