Spritam Sampling

First Name *

Last Name *

Professional Designation *

Medical Practice Name *

License # *

NPI # *

DEA ID

Office Address *

City *

State *

Zip *

Phone *

Fax *

EMail *

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.