Request Samples


Functional Formularies Product Family

Sample Request
0% Complete
1 of 2
We provide samples directly to patients at the request of healthcare providers.  If you are a healthcare provider, use this form to request samples for your patient or practice.

Requesting samples for yourself or someone else:

If you are a patient seeking samples, we REQUIRE that sample requests are made by your healthcare providers on your behalf. Please ask your healthcare provider to request samples for you and direct them to

Are you requesting samples for your patient or your practice?

Join Our Community