Spritam Sampling

* Required Field First Name *

* Required Field Last Name *

* Required Field Professional Designation *

* Required Field Medical Practice Name *

* Required Field License # *

* Required Field NPI # *

DEA ID

* Required Field Office Address *

* Required Field City *

* Required Field State *

* Required Field Zip *

* Required Field Phone *

* Required Field Fax *

* Required Field 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.

* Required Field 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

* You must agree to the terms 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.