Norgesic 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 Norgesic?

Where did you hear about Norgesic? Email Previous Use Sales Rep BeneScripts Phone Call SureMed Pod-PAC 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.