Request Samples

  • Poly Pharmaceuticals, Inc. requires that all sample requests contain the practitioner’s signature. To provide your signature, simply hold down the left cursor of the mouse and sign in the box located at the bottom of the Request Samples form prior to submitting.

    Please limit number of tablet cartons to 3, and liquid trays to 2.

  • Tablets:

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  • Liquids:

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  • Controlled liquid CV codeine:

    Must provide valid DEA number and address on DEA certificate must be same as office in order to ship to office
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