Request Samples | Poly Pharmeceuticals

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.
Clinic name*
Doctor name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Fax
State license number
NPI number
DEA number*
Tablets:
Alahist CF (NDC: 50991-0784-02)
Price: $0.00 Quantity:
Ala-Hist IR (NDC: 50991-0783-02)
Price: $0.00 Quantity:
Ala-Hist PE (NDC: 50991-0782-02)
Price: $0.00 Quantity:
Deconex IR (NDC: 50991-0736-02)
Price: $0.00 Quantity:
Deconex DMX (NDC: 50991-0740-02)
Price: $0.00 Quantity:
Duraflu (NDC: 50991-0535-02)
Price: $0.00 Quantity:
Poly-Hist Forte (NDC: 50991-0626-02)
Price: $0.00 Quantity:
Poly Vent IR (NDC: 50991-0212-02)
Price: $0.00 Quantity:
Poly Vent DM (NDC: 50991-0214-02)
Price: $0.00 Quantity:
Liquids:
Alahist DM (NDC# 50991-0826-15)
Price: $0.00 Quantity:
Poly-Hist DM (NDC: 50991-0220-15)
Price: $0.00 Quantity:
Poly-Hist PD (NDC: 50991-0222-10)
Price: $0.00 Quantity:
Polytussin DM (NDC: 50991-0132-15)
Price: $0.00 Quantity:
Signature*
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Tablets: