Request Free LODOCO Samples for Your Patients

By signing and returning, I certify I am a licensed practitioner eligible to request, receive, prescribe, and dispense these complimentary samples at the location above. If I am a Nurse Practitioner or Physician Assistant, I certify I am authorized and eligible, in the state in which I am now practicing, to request and receive these samples, and I have my supervising Physician's approval to do so. I have requested these samples for the medical needs of my patients and I will not sell, resell, trade, barter, return for credit, or seek third-party reimbursement for them.

OHIO PRESCRIBERS ONLY: I understand that Ohio law (Rev Code 4729.51) requires me (or my practice) to hold a valid Terminal Distributor of Dangerous Drugs (TDDD) license or meet an exemption to receive prescription drugs, including samples. By signing this form, I certify that I (or my practice) possess a valid OhioTDDD license for the "ship to" address on this form or I (or my practice) are exempt from the Ohio TDDD licensing requirements. Guidance from Ohio State Board of Pharmacy on prescriber licensure can be found at www.pharmacy.ohio/prescriberTDDD.

By signing this form, I agree to receive personalized commercial communication from AGEPHA Pharma by email.