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 recommend a product?




How do you typically recommend a product to a patient:




How many patient age 0-3 do you see on average monthly?
What method do you prefer for requesting samples? Rank your top 3 in order of preference.
Phone
Fax
Online
Postal
Sales Rep
How do you distribute samples in your office? (select all that apply)





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.
 
 

 

 

 
Summers Laboratories, Inc.