# Request Samples For Your Patients

Please complete and submit the form or call our customer service center at [800-325-8232](tel:+1-800-325-8232) to order samples. Physicians may order patient samples for their offices. However, we are not able to accommodate all requests for samples unless they are from specific specialties. We do not automatically send out samples on a regular basis. Please reorder as needed; however, we process sample orders every 4 - 6 weeks.

We currently are able to accommodate sample requests from dermatology, allergy, and pediatric specialties only. Thank you.

Required fields are marked *

Have you ever received samples from us before?

- Yes
- No

PSI Customer Number (if known)

**Name of Person Filling Out Form***

**Title of Provider**  
– Select One –  
MDDONPPA-CPA

**Provider's Name***

**Provider's License Number***

**Clinic/Practice Name***

**Medical Specialty**  
– Select One –  
Dermatology  
Allergy  
Pediatrics

**Office Information**

**Office Phone***

**Office Email***

**Office Fax***

**Office Website***

**Office Address***

**City***

**State***  
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Washington  
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**Country***  
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Austria  
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Cook Islands  
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Czech Republic  
Denmark  
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Egypt  
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Finland  
France  
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Gambia  
Georgia  
Germany  
Ghana  
Greece  
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Grenada  
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Guinea  
Guinea-Bissau  
Guyana  
Haiti  
Honduras  
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Hungary  
Iceland  
India  
Indonesia  
Iran  
Iraq  
Ireland  
Israel  
Italy  
Jamaica  
Japan  
Jordan  
Kazakhstan  
Kenya  
Kiribati  
Korea, North  
Korea, South  
Kuwait  
Kyrgyzstan  
Laos  
Latvia  
Lebanon  
Lesotho  
Liberia  
Libya  
Liechtenstein  
Lithuania  
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Malaysia  
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Mali  
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Nauru  
Nepal  
Netherlands  
New Caledonia  
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Nicaragua  
Niger  
Nigeria  
Norfolk Island  
Northern Mariana Islands  
Norway  
Oman  
Pakistan  
Palau  
Palestinian Territories  
Panama  
Papua New Guinea  
Paraguay  
Peru  
Philippines  
Pitcairn Islands  
Poland  
Portugal  
Puerto Rico  
Qatar  
Romania  
Russia  
Rwanda  
Saint Helena  
Saint Kitts and Nevis  
Saint Lucia  
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Samoa  
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Saudi Arabia  
Senegal  
Serbia  
Seychelles  
Sierra Leone  
Singapore  
Slovakia  
Slovenia  
Solomon Islands  
Somalia  
South Africa  
Spain  
Sri Lanka  
Sudan  
Suriname  
Swaziland  
Sweden  
Switzerland  
Syria  
Taiwan  
Tajikistan  
Tanzania  
Thailand  
Togo  
Tonga  
Trinidad and Tobago  
Tunisia  
Turkey  
Turkmenistan  
Tuvalu  
Uganda  
Ukraine  
United Arab Emirates  
United Kingdom  
United States of America  
Uruguay  
Uzbekistan  
Vanuatu  
Vatican City  
Venezuela  
Vietnam  
Wallis and Futuna Islands  
Western Sahara  
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**Zip***

**Second Office Location**

I would like to receive samples at more than one office

**How did you find out about our products?**  
– Select One –  
Advertising  
Magazine  
Pharmacist  
Mailing  
Trade Show  
Colleague

**Questions or Comments**

We are dedicated to developing specialized skin care products for the needs of physicians and their patients. Thank you for recommending our products.

Active Lifestyle  
Alcohol Free  
Botanical Extract Free  
Cocamidopropyl Betataine Free  
Dermatologist Tested  
Dye Free  
Formaldehyde Free  
Fragrance Free  
Gluten Free  
Kid Friendly  
Lanolin Free  
Non-Comedogenic  
non-greasy  
Oil Free  
Paraben Free  
Phosphate Free  
Preservative Free  
Protein Free  
Soap Free  
Sulfate Free  
Won't Clog Pores  
Zinc Oxide