Request for Samples Date: ____ / ____ / ____
Fax to: 817-595-5935 Mo. Day Year
Product Quantity
Certuss® (60 mg Carbetapentane Citrate / 1200 mg Guaifenesin)
BIPHASIC Tablets Patent Pending
Symax™ Duotab (0.125 mg Hyoscyamine Sulfate) Immediate Release
(0.250 mg Hyoscyamine Sulfate) Sustained Release
BIPHASIC Tablets Patent Pending
(60 mg Dextromethorphan Hydrobromide / 600 mg Guaifenesin /
Certuss D® Tablets 40 mg Phenylephrine Hydrochloride)
Liquibid-D® 1200 (400 mg Guaifenesin / 10 mg Phenylephrine HCI) Immediate Release
(800 mg Guaifenesin / 30 mg Phenylephrine HCI) Sustained Release
BIPHASIC Tablets Patent Pending
Liquibid-D® (250 mg Guaifenesin) Immediate Release
(40 mg Phenylephrine HCI / 400 mg Guaifenesin) 12 Hour Release
BIPHASIC Tablets Patent Pending
Liquibid®-PD Tablets (120 mg Guaifenesin / 5 mg Phenylephrine HCI) Immediate Release
(195 mg Guaifenesin / 15 mg Phenylephrine HCI) Sustained Release
BIPHASIC Tablets Patent Pending
Rescon-Jr.® Tablets (20 mg Phenylephrine Hydrochloride / 4 mg Chlorpheniramine Maleate)
(2 mg Methscopolamine Nitrate) Immediate release
Rescon® (12 mg Chlorpheniramine Maleate /
BIPHASIC Tablets Patent Pending 40 mg Phenylephrine Hydrochloride) 12 Hour Release
* Required Information
Practitioner Information: State License Number:
Name: ______________________________ __________________________________
_____MD _____DO _____NP _____PA I, a licensed practitioner, requested and
received the package quantities of the
Specialty: ___FP ___AL ___ENT ___IM products shown on this document. My
signature certifies authorization to
___Ped ___GE ___URO ___Other prescribe, receive and dispense the drug
samples requested.
Street: ______________________________
City: _______________________________
State: ________ Zip: ________________ X____________________________
* All information must be completed Signature