Tolectin DS Sample Request Form

Practitioner Name: Practitioner Name: First Last
Professional Designation
NPI Number:
State License Number:
Office Address: (SAMPLES WILL NOT BE SHIPPED TO A HOME ADDRESS) Office Address: (SAMPLES WILL NOT BE SHIPPED TO A HOME ADDRESS)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Office Phone Number: Office Phone Number: - ### - ### ####
Office Fax Number: Office Fax Number: - ### - ### ####
Office Contact Name: Office Contact Name: First Last
Office Email Address:
Where did you hear about Tolectin DS?

Where did you hear about Tolectin DS? Online Previous Use Sales Rep Other
Quantity of Tolectin DS (NDC: 71993-0309-06) Sample Cartons:
Is there a local independent pharmacy that you are currently sending Tolectin DS prescriptions to?
If so, please list their name here.
If not, information will be provided for our national fulfillment partner, Sterling Specialty Pharmacy.
Please sign here:

Draw or Type

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Full Name

I understand this is a legal representation of my signature.
Please Confirm

Please Confirm I verify that I am the person whose NPI and signature appear above.