Order Your Free Samples

Thank you for your interest in Nicomide^®! To receive free samples for your patients, please complete the sample request form below. One of our team members will be in touch shortly to confirm your sample request order. You may also call Sonia Dunson at 678.325.5313 or Spencer Watts at 678.325.5311 to request free samples of Nicomide^®.

Samples are available to prescribers only. License numbers and addresses will be verified prior to shipping.

* Required

Title

First Name *

Last Name *

Professional Designation *

Office *

Zip Code *

State License Number *

License Expiration *

Email Address *

Work Phone Number *

Comments/Enquiries *

Pay
No More Than
$25 Per Fill*

NO COUPON REQUIRED

*Most eligible patients will pay no more than $25 for each fill. For Nicomide^® the maximum benefit is $100 per fill. Patient will be responsible for any additional money due.

Order Your Free Samples

Pay No More Than $25 Per Fill*

News & Savings

Pay
No More Than
$25 Per Fill*