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.
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 sample@functionalformularies.com
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Please note: Our office and distribution services will be closed on Monday, July 4th, 2022. Orders placed July 1st - 4th will ship on Tuesday, July 5th. UPS will also not be in operation on July 4th. Please also keep our standard ordering policy in mind and plan accordingly. Dismiss