Generate a new request or use the filters to search your existing requests and monitor their current status.
| HCP Name | Address | Status | Form ID / Order ID | Submitted | Order Received | Actions |
|---|
Policy content for review.
Form ID: 1234567
Enter an email address, fax number, or both to re-send this request.
Select a State and enter at least one other detail to search.
Select a program for this request.
Search for an HCP to auto-fill this form or enter the details manually.
Select the products and quantities for this request.
| Product Name | Product ID | Quantity Limits | Requested Quantity |
|---|
Select delivery options and destination for this request.
Select at least one delivery method. Once selected, confirm or update the details below.
Include yourself and up to 2 other email addresses.
Select a tab above to make changes.
| Product Name | Product ID | Requested Quantity |
|---|
Review the certification text and required policies, then provide the HCP signature.
Your electronic signature or digital signature is required when requesting drug samples offered on the Brand A website or mobile application/website in order to comply with the provisions of the Prescription Drug Marketing Act ("PDMA").
Under 21 CFR Part 11, an electronic signature must include at least two distinct identification components. Your electronic signature is executed through secure, multi-factor authentication credentials unique to your account.
I certify that I am the person named above and agree to sign this document. I understand that this electronic signature is the legal equivalent of my handwritten signature.
I also certify that I am a licensed practitioner with the proper federal and State authority to request these drug samples.
* Required fields
A one-time secure link has been emailed to — requesting their electronic signature. You’ll be notified as soon as they sign, and this request will move to Submitted automatically – no further action is needed from you. If the link goes stale before they sign, they’ll simply need to confirm their email once to continue with this same link – no new link is ever sent, and you won’t need to do anything on your end.
Status: Request Sent
| Product Name | Product ID | Requested Quantity |
|---|
For your security, please confirm the email address this link was originally sent to. You will not be sent a new link – once verified, you can continue with this same one.
This secure link has already been used to review and sign this request. It cannot be used again.
If you believe this is a mistake, please contact the representative who sent you this request.
| Product Name | Product ID | Requested Quantity |
|---|