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Sample request formDocHubcom 2025

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The document is a sample request form for DIOVAN and DIOVAN HCT from Novartis Pharmaceuticals Corporation. It outlines the necessary information that licensed practitioners must provide to request samples, including personal details, product selection, and a signature certifying eligibility. The form emphasizes the prohibition of selling or trading the samples and includes instructions for submission via fax.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your details in the 'Practitioner’s Last Name, First Name' field. Ensure accuracy as this information is crucial for processing your request.
Fill in your 'State License Number' exactly as it appears on your certificate. This is a mandatory field for sample shipment.
Provide the 'Expiration Date' of your license and include your 'ME Number' if applicable.
Complete the address section with your office's physical address (no P.O. Boxes), including city, state, and ZIP code.
Enter your contact information by filling out the 'Phone #' and 'Fax #' fields.
Select the quantity of samples you wish to receive by checking the appropriate boxes for DIOVAN or DIOVAN HCT options.
Sign in the designated area using an original ink-written signature, and date it accordingly. Remember that signature stamps are not accepted.

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