Sample Request Form  Product

Sample Request Form
Thank you for your interest in obtaining FSC Pediatrics samples!
To receive samples, please complete this form, sign and date it and fax it to 407-641-9776 or email to [email protected]
Medical Practice Name
Address
City
State
Phone
Fax
Zip/Postal Code
Product
NDC#
Size
Quantity
Besivance® (besifloxacin ophthalmic
suspension) 0.6%
24208-446-02
2mL
 1
 2

3

4
Bepreve® (bepotastine besilate
ophthalmic solution) 1.5%
24208-629-10
1 mL


2

3

4
Primsol® Solution (trimethoprim
hydrochloride 50 mg / 5 mL)
13551-501-01
20mL
 1
 2

3

4
1
*Please allow 10 days for delivery.
“By signing this form I certify that I have requested the items listed above in the quantities designated. I further certify that I am a licensed
practitioner eligible to receive and prescribe these samples. If I am a Nurse Practitioner or Physician Assistant, I certify that I am authorized
and eligible in the state within which I am currently practicing, to request and receive these samples and that I have my supervising
Physician’s approval to do so. My signature on this form certifies that I recognize that sample products are for the medical needs of my
patients and will not be sold, traded, bartered, returned for credit or utilized to seek or obtain reimbursement.”
MD DO NP PA Other (Please Specify) 
Professional Designation
NPI #

License Number
State of Licensure
Practitioner’s E-mail Address
Authorizing Practitioner Name (Print)
Specialty
Authorizing Practitioner Signature (NO Stamps)
Date
You can find product information at www.fscpediatrics.com. If you have any questions regarding the FSC Pediatrics product
sampling program, please contact FSC at (704) 941-2500.
FSC Representative Name
Territory Number
BESIVANCE & BEPREVE are manufactured and distributed by Bausch & Lomb Inc., 8500 Hidden River Parkway, Tampa, FL 33637 (Florida Manufacturer permit # 20:00038), and marketed by:
FSC Pediatrics, Inc. 6000 Fairview Road, Suite 600, Charlotte, NC 28210.
Primsol® Solution is manufactured for and distributed by: FSC Laboratories, Inc. 6000 Fairview Road, Suite 600, Charlotte, NC 28210
BESIVANCE & BEPREVE are registered trademarks of Bausch & Lomb Incorporated or its affiliates.
All other product/brand names are trademarks of their respective owners.
US/BEP/12/0021d(1)b
2014 FSC Laboratories, Inc.
050814001 Rev 0 May 2014
US/BEP/12/0021d(1)b