Sample Request

Brief Questionaire

Welcome to the Triple Paste online sample request page. Before submitting your request* we ask that you answer a few brief questions regarding Triple Paste. We greatly appreciate your support!

Thank You - Summers Labs
*Please note this sample request form is intended for doctors, pediatricians and healthcare providers in the US ONLY. If you represent a pharmacy please call (800)533-7546.

How does the availability of a sample influence your decision to recomend a product? *	None Somewhat Strongly Very Strongly
Who makes the decision to request more samples? *
Who typically submits the request? *
What method do you prefer for requesting samples? *	Phone Fax Online Postal Sales Rep
On a typical day what percentage of your patients receive samples? *
First Name *
Last Name *
Title
Practice Name *
Prescribing Doctor *
Specialty *
Street Address 1 *
Street Address 2
City *
State *
Zip *
Phone # *
Email *
Yes I would like to be included in future email correspondence from Summers Labs
By filling out this registration for the Triple Paste® sample and coupon by mail offer, you agree to receive additional product information/future promotions from Summers Labs. We will never sell or rent your information.