Sample Request

Vivelle-Dot^®: The Smallest ET Patch Available

Please enter your information below to generate a Sample Request Form to receive samples of Vivelle-Dot, the smallest ET patch available for the treatment of moderate to severe menopause symptoms and the prevention of postmenopausal osteoporosis.¹

		FILL OUT this form completely. (Complete all required fields) ^*Required Fields.

^*First Name:

Middle Initial:

^*Last Name:

^*Practitioner's Designation:

^*Practice Name:

^*State License Number:

^*Expiration Date:

^*Address:

P.O. Boxes Are Not Accepted

Suite/Floor:

^*City:

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^*Zip:

^*Office Phone Number:

(in the format XXX-XXX-XXXX)

^*Office Fax Number:

(in the format XXX-XXX-XXXX)

^*E–mail Address:

Please check box for each sample dose requested

DESCRIPTION	NDC	QTY
Vivelle-Dot 0.025 mg/day	0078936501	10 boxes (20 patches)
Vivelle-Dot 0.0375 mg/day	0078934301	10 boxes (20 patches)
Vivelle-Dot 0.05 mg/day	0078934401	10 boxes (20 patches)
Vivelle-Dot 0.075 mg/day	0078934501	10 boxes (20 patches)
Vivelle-Dot 0.1 mg/day	0078934601	10 boxes (20 patches)

Please do not change the designated quantities; otherwise, the sample request will be denied. Samples will be distributed via courier within two weeks of request.

The information I provided here may be used by Novogyne Pharmaceuticals to contact me in the future.
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Click here for the Full Prescribing Information for Vivelle-Dot.

The information contained within this Web site is appropriate for U.S. healthcare professionals only.

^*IMS Health^® National Prescription Audit Plus^™, April 2008

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Sample Request

Vivelle-Dot®: The Smallest ET Patch Available

Vivelle-Dot^®: The Smallest ET Patch Available