Emollient Clinical Sample Request Form (ADoc 308)

Emollient clinical sample request form

EPIMAX^® Eyelid Ointment and EPIMAX^®Gentle Wash

If you are a healthcare professional and would like to order clinical samples of our EPIMAX^® Eyelid Ointment and EPIMAX^® Gentle Wash, please complete the form below.

If you would like to order patient demonstration samples of the rest of the products in our EPIMAX^® range, please also fill out our Emollient Patient Demonstration Sample Request Form.

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

Department

Address (Required)

Hospital, surgery or clinic name Address City County Post code

Phone number(Required)

Email(Required)

ICB Information

Please provide us with some details about which ICB your hospital, surgery, clinic or institution belongs to.

Location

ICB

The ICBs below are listed in alphabetical order.

ICB

The ICBs below are listed in alphabetical order.

Sample selection

EPIMAX Eyelid Ointment (4g)

Please enter a number from 1 to 1.

EPIMAX Gentle Wash (500g)

Please enter a number from 1 to 1.

Please advise your patients to always read the label.

Adverse events should be reported.
Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Aspire Pharma Ltd on 01730 231148.

MAT-UK-EPI-0196-1 | June 2026