Patient Sample Request

Interested in samples for your patients?
Fill in the request form below and we will do the rest.

Patient Sample Request Form
This is so we can send the most appropriate information and samples to you. This request form is for healthcare professionals only.
This is so we can verify your address / profession. Unfortunately we cannot send samples without being able to verify your place of work as a healthcare provider.
Please select your state

For more information about Hydralyte or¬†questions that patients may ask, please view¬†our FAQ’s here