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Requesting a sample as a healthcare professional
Please fill out all fields below in order to receive a free sample.
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Fields marked with * are mandatory.
Your Information
First Name
*
Please enter first name.
Last Name
*
Please enter last name.
Healthcare Professional Type
*
SELECT ONE
Pediatric Gastroenterologist
Allergist
Pediatrician
Registered Dietitian
Other
Please select healthcare professional type.
Specify
*
Please specify other.
Email Address
*
Please enter your e-mail address.
Please enter a valid e-mail address.
Clinic/Practice Name
*
Please enter healthcare professional clinic name.
Office Phone
*
Please enter office phone.
How did you hear about the sample program?
*
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Banner Ad
Social Media
Postcard
Event
Email
Web Search
This website
A Nutricia representative
Other
Please specify where did you hear about us.
Specify
*
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What is the purpose of the sample?
*
To trial with my patient - please send directly to patient
To become familiar with Pepticate - please send to my clinic/practice
Please specify what is the purpose of the sample.
Formula to Sample
*
SELECT ONE
Pepticate - 1 can (375g)
Pepticate - 2 cans (375g)
Pepticate - 3 cans (375g)
Please select formula to sample.
Order Reason
*
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Sales
Marketing
Order Reason is required.
I have my patient's permission to provide their information to Nutricia North America.
Patient Information
Patient First Name
*
Please enter patient first name.
Patient Last Name
*
Please enter patient last name.
Patient Date of Birth
*
Please enter date of birth.
Patient Email
*
Please enter your patient email address.
Please enter a valid patient email address.
Last formula used before trying Pepticate™
SELECT ONE
Similac®
Enfamil®
Alimentum®
Nutramigen®
Aptamil™
Other
Specify
*
Please specify other.
Diagnosed Medical Condition
SELECT ONE
Cow milk allergy
Other
Specify
*
Please specify other.
Shipping Information
Note: We cannot ship to P.O. box addresses. Samples can only be request in the U.S.
Please enter shipping information below
First Name
*
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Last Name
*
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Address via Address Finder
Address 1
*
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Address 2
City
*
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State
*
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Zip
*
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Enter Security Code Below
*
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