Diovan Sample Request Form PDF Details

Healthcare professionals seeking to provide patients with Diovan or Diovan HCT now have the convenience of requesting samples directly from Novartis Pharmaceuticals Corporation through a straightforward sample request form. This form, which must be returned via fax to the provided number, streamlines the process, ensuring that practitioners can quickly and efficiently receive these vital medications for their patients. To ensure a seamless transaction, the form requires comprehensive information, including practitioner's full name, state license number with its expiration date, contact details, and a specific request regarding the desired medication samples. Importantly, it mandates an original ink signature from the requesting licensed practitioner, underlining the legal and ethical responsibilities involved in requesting and handling medication samples. The form advises on the available types and quantities of Diovan and Diovan HCT samples, clarifying that these are intended strictly for patient care and not for resale. Novartis also emphasizes compliance with federal regulations, noting that incomplete requests will not be honored, and highlights the necessity of acknowledging sample receipt as per federal law. This efficient system ensures practitioners have access to necessary medications, while maintaining strict adherence to legal requirements and ethical standards in patient care.

QuestionAnswer
Form NameDiovan Sample Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesDIO 1040743_Q1_2011 _Sample_Request _Fax_Form_Diova n_Med_Wave2Hype rlinked sample request formpdffillercom

Form Preview Example

DIOVAN and DIOVAN HCT

Rx SAMPLE REQUEST FORM

Return Completed Form via Fax to: 1-888-697-7607

Dear Licensed Practitioner:

Thank you for requesting samples from Novartis Pharmaceuticals Corporation. In order to expedite your sample request, please complete the information below and fax to the number listed above. Incomplete requests will not be processed. Shipping is via UPS. Please allow 5–10 business days for delivery. For any product-related questions concerning DIOVAN or DIOVAN HCT, please call 1-877-HYPER-10 (1-877-497-3710).

 

MD c DO c

NP c PA c

Practitioner’s Last Name, First Name

 

 

State License Number

Expiration Date

ME Number

Print the STATE LICENSE NUMBER exactly as it appears on the certificate. This number is required to allow samples to be sent.

Address (No P.O. Boxes)

City, State, ZIP Code

Phone #

Fax #

Please select to receive:

c 8 units of DIOVAN 160 mg c 4 units of DIOVAN 320 mg

c 8 units of DIOVAN HCT 160/12.5 mg c 4 units of DIOVAN HCT 320/25 mg

Please see accompanying full Prescribing Information, including Boxed WARNING for DIOVAN and DIOVAN HCT

or please go to www.quo.novartis.com/product/DIOVAN.

SIGNATURE REQUIRED Original ink-written signature of licensed practitioner required (no signature stamps).

X

Date of Signature

My signature certifies that I am a licensed practitioner eligible to request and receive these samples. The samples are being requested for the medical needs of my patients and are not intended for, and are prohibited from, sale, trade, barter, and return for credit. I understand that I may not seek or accept any reimbursement for these samples as I will not incur any cost in relation to them. I understand that Novartis Pharmaceuticals Corporation will mail these samples directly to my office and that I will be required by federal law to sign an acknowledgement of delivery.

As per federal regulations, incomplete requests cannot be processed.

Novartis Pharmaceuticals Corporation

 

 

 

 

East Hanover, NJ 07936

 

 

 

 

©2011 Novartis

Printed in USA

VSNWB0023

2/11

DIO-1040743

How to Edit Diovan Sample Request Form Online for Free

You may fill out Diovan Sample Request Form easily using our online tool for PDF editing. The editor is constantly maintained by our team, getting new features and becoming greater. To begin your journey, take these basic steps:

Step 1: Just click on the "Get Form Button" above on this site to launch our form editor. Here you will find all that is necessary to work with your file.

Step 2: The editor gives you the opportunity to customize your PDF file in various ways. Modify it by adding personalized text, correct existing content, and put in a signature - all doable in no time!

As a way to fill out this PDF form, make sure you provide the required information in every single blank field:

1. While filling in the Diovan Sample Request Form, make certain to include all of the essential blanks in its corresponding form section. This will help to hasten the work, enabling your information to be handled quickly and appropriately.

Diovan Sample Request Form completion process described (part 1)

Step 3: When you've looked over the details in the file's blank fields, click on "Done" to conclude your form at FormsPal. Join us now and instantly use Diovan Sample Request Form, ready for downloading. Every last edit made is handily preserved , making it possible to edit the form at a later time when required. With FormsPal, you'll be able to complete forms without the need to be concerned about personal information incidents or records getting shared. Our secure system helps to ensure that your private details are maintained safely.

Diovan Sample Request Form isn’t the one you’re looking for?

Related Documents