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 Horn 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

with our instant savings coupon*

*This offer is subject to the Eligibility Terms and other requirements on the back of the downloadable voucher.

order your free samples

pay no more than $25 per fill

news & savings