Norgesic Sample Request Form
Norgesic Sample Request Form
Practitioner Name:
Practitioner Name:
*
First
Last
Professional Designation
*
M.D.
D.O.
P.A.
N.P.
D.N.P.
A.R.N.P.
D.M.D.
D.D.S.
D.P.M.
Other
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
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal / Zip Code
Country
United States
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 Norgesic?
*
Where did you hear about Norgesic?
Email
Previous Use
Sales Rep
Other
Quantity of Norgesic (NDC: 71993-0304-06) Sample Cartons:
*
Quantity of Norgesic (NDC: 71993-0304-06) Sample Cartons
*
Is there a local independent pharmacy that you are currently sending Norgesic 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.