Physician Sample Request Page
Attention Health Care Providers:
Please enter you name and the address of your practice as it appears in your local phone directory.

NOTE:  COMPLIMENTARY SAMPLES AVAILABLE TO DOMESTIC U.S.A. PHYSICIANS ONLY.   PLEASE
PROVIDE THE TELEPHONE NUMBER AND PHYSICAL ADDRESS OF YOUR PRACTICE AS LISTED IN
YOUR LOCAL PHONE DIRECTORY.

Physician Name
Address Line 1
Address Line 2
City
State
Zip
Telephone  
Fax Number (Optional)
E Mail Address
   
How Did You Hear About Rhinostat?

      Annual Meeting
      From A Patient
      Other

If you were referred by another physician, please provide his or her information below.

Physician Name

City                                                                      
  
State

Please Specify An Active Compound:

It is essential that patients receive a kit which contains the same active compound as their current decongestant nasal spray.  If you are unsure, it is best to check with the patient before ordering.

This table illustrates the relative popularity of each compound within the USA patient base:

Oxymetazoline hcl Most Common > 81%
Phenylephrine hcl Less Common < 15%
Xylometazoline hcl Uncommon < 3%
Naphazoline hcl Rare < 1%

For Afrin, choose Oxymetazoline. 

Number Of Kits Requested:
 Normally a single person will need only one kit. 
How many kits would you like to order ? 

All kits are shipped via UPS Ground or Priority Mail

Comments or special request here: