For Medical Professionals

Request Samples For Your Patients

Please complete and submit the form or call our customer service center at 800-325-8232 to order samples. Physicians may order patient samples for their offices. However, we are not able to accommodate all requests for samples unless they are from specific specialties. We do not automatically send out samples on a regular basis. Please reorder as needed; however, we process sample orders every 4 - 6 weeks.

We currently are able to accommodate sample requests from dermatology, allergy, and pediatric specialties only. Thank you.

Required fields are marked *

Have you ever received samples from us before?

Yes

PSI Customer Number (if known)

Name of Person Filling Out Form*

Title of Provider

Provider's Name*

Provider's License Number*

Clinic/Practice Name*

Medical Specialty

Office Information

Office Phone*

Office Email*

Office Fax*

Office Website*

Office Address*

City*

Zip*

Second Office Location

I would like to receive samples at more than one office

How did you find out about our products?

Questions or Comments

[data-disabled-noscript="true"] {display: none !important;}Please enable JavaScript to get a reCAPTCHA challenge.
Learn more about ReCAPTCHA.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Office Hours: Monday – Friday, 8 am – 5 pm CT
Phone: 1-800-325-8232 or 507-288-8500
Fax: 507-288-7603
We are dedicated to developing specialized skin care products for the needs of physicians and their patients. Thank you for recommending our products.