Tolectin® Sample Request Form

Tolectin® Strength

Tolectin® Strength Tolectin®DS Capsules (NDC: 71993-0309-06) Tolectin® Tablets (NDC: 71993-0312-04)
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®?

Where did you hear about Tolectin®? Online Previous Use Sales Rep Other
Quantity of Sample Cartons:
Is there a local independent pharmacy that you are currently sending Tolectin® 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

I understand this is a legal representation of my signature. Clear

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.