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Vitaflo USA Sample Request


  • Please choose the proper country for sample request
  • Sample Kit (please choose the medical condition and product you would like to sample)
  • Choose your products
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  • Sample Information
  • Person Requesting Sample
  • Email
  • Email confirmation
  • First name (individual receiving product sample)
  • Last name (individual receiving product sample)
  • Patient Date of Birth (MM/DD/YYYY)
  • Comments or special requests
  • How did you hear about this program?

  • Shipping Information
    *please note, we do not ship to P.O. Box Addresses
  • Street address
  • Address line 2
  • City
  • State
  • Zip Code
  • Home Phone number

  • Medical Information
    We ask for your Healthcare Professional information since our products are categorized by the FDA and will require authorization prior to shipping.
  • First name
  • Last name
  • Healthcare Professionals Phone number
  • Is Patient currently attending clinic
  • In which state is your clinic?
  • Clinic Name
  • Medical condition
  • Protein prescription if known
  • How many grams of protein equivalent / day?
  • Current formula
  • How do you obtain your formula (e.g. DME, pharmacy, etc.)
  • If you are a Dietitian or Physician requesting a sample for your patient, please enter your RD or Physician license number
  • Vitaflo seeks authorization for all samples by a Healthcare Professional prior to shipping. I agree to sample authorization and accept the Terms of Use of this website. If you require any assistance, please call 888-848-2356 (Tick box)
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Privacy Statement & Authorization to Share Information:
Your privacy is important to Vitaflo USA, LLC (Vitaflo). Personal information collected by Vitaflo may be shared with Vitaflo’s affiliates, agents and contractors as well as other outside organizations (including healthcare providers, health plans and other product and service providers) to help provide patients with reimbursement support, including benefit verification, prior authorization and other reimbursement services. Additionally, Vitaflo and its affiliates and agents may use this information to contact patients about Vitaflo and its products and services. By submitting this information, I agree that Vitaflo and the outside organizations with which Vitaflo shares this information may contact me at any of the telephone numbers, including cell phone numbers, or email addresses provided. Vitaflo will not sell or rent personal information to others.