Order EPIMAX Samples

Emollient Patient Demonstration

Sample Request Form

If you are a healthcare professional and would like to order patient demonstration samples from our EPIMAX^® range, for your patients, please complete the form below.

Name (Required)

First Last

Job Title or Speciality(Required)

Institution (if applicable)

Registered Council (Required)

Please select which council you are a member of from the options below. You will then be prompted to input your registration number.

Registration number(Required)

Please provide your registration number to aid with the verification of your form submission.

Delivery Address

This must be a clinical address unless you work from a private practice

Department

Address (Required)

Hospital, surgery or clinic Address City County Post code

Phone number(Required)

Email(Required)

Sample selection

Minimum sample units: 5 (excluding EPIMAX Eyelid Ointment and EPIMAX Gentle Wash). For orders over 100 units per product, please contact your Key Account Manager.

Please enter the quantity of free patient demonstration samples required: