First Name *
Last Name *
Professional Designation *
Medical Practice Name *
License # *
NPI # *
Office Address *
Collaborative Physician's Last Name
Collaborative Physician's First Name
Collaborative Physician's License #
Please check the box below to request your drug samples. Only one sample of each strength may be requested at a time.
Spritam (levetiracetam) Tablets for Oral Suspension 250mg per tablet. 6 units per sample pack provided. 6 tablets per unit. NDC: 43485-101-06 AND Spritam (levetiracetam) Tablets for Oral Suspension 500mg per tablet. 6 units per sample pack provided. 6 tablets per unit. NDC: 43485-102-06
Please see US
Full Prescribing Information and Medication Guide
I certify that I am a licensed practitioner eligible under state law and my collaborative agreement to prescribe, request, receive and dispense samples of the drugs provided. Furthermore, I have requested these samples for the medical needs of my patients and I acknowledge that they are not for sale, resale, trade, barter, return for credit or for third party reimbursement. I also acknowledge my name and the quantity of samples I receive may be reported as required by state and federal law. Submitting this form constitutes my electronic signature.
Sample Request Form
10901 Kenwood Rd.
Blue Ash, Ohio 45242