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Sample Request

  • Please choose the proper country for sample request
  • Sample Kit (please choose the medical condition and product you would like to sample)
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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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