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PHYSICIAN SAMPLE RECEIPT FORM
Pharmelle (Division of Azur Pharma Inc.) ▪ Gilbert, AZ ▪ (877) 577-2577 Fax ▪ (480) 926-5665
Date: __________________
Name of Licensed Practitioner: ________________________________________ DEA or License #:________________
Office Name & Address: _____________________________________________________________________________
♦Signature of Licensed Practitioner:___________________________________________________________________
Package Lot Package Lot
Product Name Size Number Qty. Product Name Size Number Qty.
Natelle® Plus w/ DHA Natelle® Plus w/ DHA
66663-333-90 1 x 90 66663-333-30 1 x 30
66663-333-00 18 x 3
Natelle® Urelle®
66663-317-01 1 x 90 66663-219-01 1 x 90
66663-317-00 12 x 3 66663-219-00 12 x 2
samples samples
Natelle® Prefer Pyrelle™HB
66663-330-01 1 x 90 66663-702-01 1 x 30
66663-330-00 12 x 3 66663-702-00 12 x 1
samples samples
Natelle® EZ RectaGel™HC
66663-668-01 1 x 90 66663-620-01
66663-668-00 12 x 3 66663-620-00
samples
Natelle®C MagGel™600
66663-724-01 1 x 90 66663-211-01 1 x 60
66663-724-00 12 x 3 66663-211-00 1 sample
samples
MigraTen™ Femtabs®
66663-112-01 1 x 100 66663-517-01 1 x 90
66663-112-00 12 x 2 66663-517-00 12 x 3
samples samples
Instructions for Licensed Practitioner:
• Print off multiple copies of this form for possible future use
• Complete top information, fill in requested quantities and sign
• Fax to (480) 926-5665
• After verifying information and license number, samples should arrive in 7 – 14 days
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