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SAMPLE REQUEST FAX FORM Fax to 973-644-2386

SAMPLE REQUEST FAX FORM Fax to 973-644-2386-2026

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The document is a sample request fax form for healthcare practitioners to order samples of Osphena (ospemifene) tablets, which are indicated for treating moderate to severe dyspareunia and vaginal dryness due to menopause. It outlines the necessary information required from the practitioner, including personal details and product request specifics. The document also includes important safety information, contraindications, warnings about potential risks such as endometrial cancer and cardiovascular disorders, and instructions for proper use. Additionally, it provides guidance specific to Ohio prescribers regarding licensing requirements and record retention.

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Click ‘Get Form’ to open the SAMPLE REQUEST FAX FORM in our platform's editor.
Begin by filling in the 'Practitioner’s Last Name' and 'First Name' fields, ensuring both are completed as they are required.
Select your 'Professional Designation' from the dropdown menu. Options include MD, DO, or NP; choose one that applies to you.
Enter your office address in 'Office Address Line 1'. Note that PO boxes are not accepted. Complete the city, state, and zip code fields.
Provide your phone number and optional email address for further communication.
In the 'Product Request' section, select either '5 Sample Units (5ct/unit)' or '10 Sample Units (5ct/unit)' based on your needs.
Sign the form in the designated area to certify that you are a licensed practitioner authorized to request these samples.
Finally, review all entered information for accuracy before submitting the form via fax to 973-644-2386.

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