Sample Request

Physician’s Sample Request Form
Order Samples for Your Office

Fill in the information below and click on the Submit button to request samples or call 1-866-858-5260

Attention: This site is for physicians only and not for consumer use.

Please send me:

Samples
NAFTIN^® (naftifine HCl) Cream 2%
10 2g tubes

Samples
NAFTIN^® (naftifine HCl) Gel 1%
10 2g tubes

Merz Medical Dermatology Co-pay Savings Cards will accompany your samples

*Physician's First Name:

*Physician's Last Name:

*Professional Designation:

*Telephone:

Fax:

E-mail:

By providing your e-mail address, you agree to receive communications about NAFTIN^® and other information from Merz

Full shipping address (No PO Boxes)

*Street Address:

*City:

*State:

*ZIP Code:

Date of request:

*State License #:

*Expiration date:

I certify that I am a licensed practitioner eligible to request and receive these samples under state law.

Fields marked with one * are required

Note: If you are faxing this form, please print it out and sign here:________________________________
Fax completed form to 1-866-227-2380

If you have questions about your sample request, please contact us toll-free at 866-858-5260.

Merz Pharmaceuticals, LLC
4215 Tudor Lane
Greensboro, NC
27410-8105 USA
www.merzusa.com

Merz Pharmaceuticals Distribution by: Triplefin

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