HCP Sample Request | Novartis US

Health Care Professional Sample Request Form

Thank you for your interest in Novartis Pharmaceuticals Corporation. You may submit one request per month for each Health Care Professional. Please be sure to complete each of the required fields below when you submit your request. Your request will be reviewed for eligibility and will be addressed in a timely manner.

This form should NOT be used to report Adverse Events. To report Adverse Events, please click here.

Our Customer Interaction Center can also be reached by phone at:

1-888-NOW-NOVA (1-888-669-6682) Monday–Friday, 8:30 AM–5:00 PM (ET)

Please note all fields with an asterisk (*) are required.

Practice Name

Practice Contact Name

Practice Email

Salutation

HCP First Name

HCP Last Name

Degree

Primary Specialty

State License #

Practice Address 1

Practice Address 2 (Optional)

City

State

ZIP

Practice Phone (a direct number where we can reach you)

Enter the name and dosage of the product samples you are requesting below. Please note that samples are subject to limitations, and the availability of samples is not guaranteed.

You can type up to 300 characters into this window and check the character count as you go.

Character Count:

300

The information we collect from you will be used as provided in our Privacy Policy, including to respond to your request. By submitting this form, you understand that eligibility to receive samples is not guaranteed.

After submitting your request, you may continue to edit HCP and sample information, and submit the form again.

Thank you for your interest in Novartis Pharmaceuticals Corporation.

Your request has been successfully submitted.

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