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Sample Release Order Form
Fields marked with * are required
Practice Information
* Clinic/Practice Name
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* Email
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* Salutation
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* Healthcare Practitioner Name
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* Clinic/Practice Address
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Apt/Suite (Optional)
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* City
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* Country
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Canada
Province/State
Alberta
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Quebec
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Fax (Optional)
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* Name of Contact on Staff
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Additional Comments (Optional)
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Order Type:
New
Renew
Please Specify:
Vitamin D
Baby Ddrops
®
400 IU Samples (15 dose bottle)
Ddrops
®
Booster 600 IU Samples (15 dose bottle)
Ddrops
®
1000 IU Samples (15 dose bottle)
Vitamin D Brochures English
Vitamin D Brochures French
DHA Omega-3
Thinkmist
TM
DHA Brochures English
Symptom Relief
Coldrops
®
Samples (15 drop bottle) - Adult symptom relief
Kids Coldrops
®
Samples (15 drop bottle) - Children 5 - 12 years
Coldrops
®
Brochures English
Coldrops
®
Brochures French
* I AGREE, I have read and agree to the privacy policy and terms on the Ddrops website prior to submitting this sample request form.
* By providing this information and submitting this form, I agree to accept samples and agree to periodic contact via phone, fax and/or email using my professional contact information I have provided above for the purposes of following up on the samples or material.
Yes, I consent to receiving industry-specific special promotions, announcements and other marketing information from Ddrops Company using my email address, fax or mailing address contact information provided.
You have the option of modifying or discontinuing the samples program and/or the marketing promotions program at any time. You may contact Ddrops Company at
healthcare@vitaminddrops.com
or 1-844-433-7677 or by mail at 126 Trowers Road, Woodbridge, Ontario, Canada, L4L 5Z4.
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