Diovan Sample Request Form PDF Details

There are many pharmaceuticals on the market, and they all have different sample request forms. Diovan is a relatively new medication that has been released in the past few years, so you may be wondering what the process is for obtaining free samples of it. Here we will outline the steps you need to take to get your hands on some free Diovan samples. Diovan is a hypertension medication that can help people who have high blood pressure to lower their blood pressure readings. It comes in tablet form, and there are two different dosages available: 80 mg and 160 mg. If you are interested in trying out this medication before committing to a full prescription, requesting a free sample is your best bet. In this post, we will tell

Form NameDiovan Sample Request Form
Form Length1 pages
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



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).


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




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Diovan Sample Request Form completion process described (part 1)

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