Samples Request

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The first and only once-daily amoxicillin1,2

Moxatag®. 1 Tablet Once Daily. 10 Days1.

Samples Request Form

Practitioner's Full Name*
Type*
Street Address*
City*
State*
Zip*
( Format: 12345-1234 )
Phone*
( Format: 123-456-7890 )
Email*
Signature ( Type Name )*
Today's Date*
State License Number*
License Exp. Date*
( Format: 01/01/2014 )
* My signature certifies that
1) The information provided is complete and accurate to the best of my knowledge;
2) I am licensed to prescribe, receive and dispense the drug samples requested;
3) These samples have been requested for the medical needs of my patients;
4) I understand that it is strictly prohibited to take these samples and sell, trade, barter, return for credit, or submit to Medicare/Medicaid or any third party for reimbursement.
* I verify that the recipient is eligible to receive samples. I understand that the entry of my name on this form will be used as the electronic equivalent of my handwritten signature.
 

References: 1. Moxatag© [package insert]. Berwyn, PA: Vernalis Therapeutics, Inc; 2016. 2. Orange Book: Approved drug products with therapeutic equivalence evaluations. US Food and Drug Administration website. http://www.accessdata.fda.gov/scripts/cder/ob/. Accessed April 28, 2016.

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