Sample Request for Medical Professionals
Sample Request for Medical Professionals
Please check desired products you would like to receive Free Samples of.
Project Number
Sinus Rinse Kit
NasaFlo NetiPot
Sinus Rinse Pediatric Kit
NasaDrops Saline on the Go
PediaMist
NasaBulb
SinuFlo ReadyRinse
NasaMist All in One
NasaMist Isotonic
NasaMist Extra Strength Hypertonic
Sinugator
Clearcanal
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
Name
Name
*
First
Last
Academic Title
*
Professor
Assistant Professor
Research
Program Director
Director
Other
University Affiliation
Facility Name
*
Speciality
*
Allergy
Anesthesiology
Cardiology
Dentist
Emergency medicine
ENT
Family medicine
General Practice
Geriatrics
Holistic Medicine
Intensive care medicine
Infectious disease
Oncology
Otolaryngology
Obstetrics and gynaecology
Pediatric surgery
Pulmonology
Pediatrics
Rheumatology
Other
Address
Address
*
Street Address
City
County
Postcode
Country
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
-------
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
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Greece
Grenada
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
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Hungary
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Israel
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Japan
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Lesotho
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Libya
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Malaysia
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Mali
Malta
Marshall Islands
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Mauritius
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Monaco
Mongolia
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Morocco
Mozambique
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Nauru
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New Zealand
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Niger
Nigeria
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North Korea
Oman
Pakistan
Palau
Palestine
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Papua New Guinea
Paraguay
Peru
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Portugal
Puerto Rico
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Romania
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Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
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Saudi Arabia
Senegal
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Seychelles
Sierra Leone
Singapore
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Slovenia
Solomon Islands
Somalia
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South Korea
Spain
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Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
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Tanzania
Thailand
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Tonga
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Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Phone (Please enter main facility phone without space)
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Fax
Email
*
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