healthcare professionals
REQUEST FOR PROFESSIONAL SAMPLES
To request personally-delivered samples of AquADEKs™, please complete the following information and e-mail or fax this form to the Axcan Pharma™ Customer Service Department at (205) 991-8426.
PHYSICIAN NAME:
AFFILIATION:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE:
FAX:
EMAIL:
Please indicate which sample product(s) you would like to receive: AquADEKs™ Softgels AquADEKs™ Pediatric Liquid
AXCAN PHARMA™ SAMPLE PRODUCT
SAMPLE SIZE
14 softgels per bottle
2 fl. oz (60 ml) per bottle
FOR USE BY AXCAN PHARMA™ CUSTOMER SERVICE DEPARTMENT
DATE RECEIVED:
DATE PROCESSED:
REGION:
Trademarks are owned by their respective companies.
The information provided in this secton is intended for United States Healthcare Professionals only.
