First Name *
Last Name *
MD
NP
DO
PA
Professional Designation *
Medical Practice Name *
License # *
NPI # *
DEA ID
Office Address *
City *
State *
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Phone *
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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
at
www.spritam.com
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.
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Sample Request Form
Questions?
Please Call:
1-844-SPRITAM
(1-844-777-4826)
Aprecia Pharmaceuticals
10901 Kenwood Rd.
Blue Ash, Ohio 45242
USA