Sample Request for Medical Professionals

NASAL • SINUS • ALLERGY • COLD • HAY FEVER

NeilMed Pharmaceuticals

Please check desired products you would like to receive Free Samples of.

Sinus Rinse™ Kit
NasaFlo NetiPot
Sinus Rinse™ Pediatric Kit
NasaDrops Saline on the Go
PediaMist
NasaBulb
Sinugator
Clearcanal
SinuFlo Ready Rinse
NasaMist All in One
NasaMist Isotonic
NasaMist Extra Strength Hypertonic
NasoGel Spray
NasoGel Tube
Neilcleanse WoundWash
NasaDock Plus
I will accept only doctor’s recommendation pads or brochures as my clinic cannot accept physical samples.
Please select the appropriate option

Please select the appropriate option Requesting samples for first time I want to update address
24-page Educational Rhinosinusitis Brochures

24-page Educational Rhinosinusitis Brochures 50 100
May we place your name on our mailing list for samples and educational brochures to be sent every 3 months?

May we place your name on our mailing list for samples and educational brochures to be sent every 3 months? Yes No
These samples requested are for my personal evaluation

These samples requested are for my personal evaluation Yes No
Send wholesale price list with samples

Send wholesale price list with samples Yes No
Address should not be a PO Box and should be able to receive UPS or Fedex Package
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