Free Sample Request Form

Professional Title*

First name*

Last name*

Phone number*

NPI #*

Email*

Practice name*

Street address*

City*

State/Region*

Zip Code*

Website URL

SCLERO Sample Package

I will be using these samples for.....*

Samples for my patients

Samples for personal use

Samples for both patients & myself

How many patients visit your practice each week?

How were you referred to our company and/or our products?*

Do you currently recommend our products to your patients? *

Do you recommend any other related products? If so, which ones?

Any other Questions / Comments / Patient Feedback?

Some things to remember when recommending:

The best place to send patients who are interested in purchasing would be directly to our websites – which are listed in the samples and brochures.

There will also be discounts for the patients to redeem ranging from 5-10% off. These are only valid through us.

Patients have questions? Have them call us directly at 1-800-214-9600 and they can speak to a live customer service representative.

Our brands work and patients will benefit from them. However, it is important to explain how long they should stay on the products in order to see optimal benefits.

And finally, when recommending patients, have them reference your name so that we may link the order with your account. The more customers you recommend the more samples we can provide.

Any questions contact us directly at 1-800-214-9600 or at info@wynnpharm.com