The Request Process

Requesting samples

  1. Check the box next to the samples you want and click Continue. If available, check the box to enable Recurring Requests.
  2. Choose your shipping address or add a new one.
  3. Enter your state license number.
  4. Click Confirm Sample Request.
    • Via fax: Click Print Request Form, fill out the form, and fax it.
    • Via mobile: Sign on your mobile device.

Printing vouchers and coupons

  1. Select the printer icon next to a brand.
  2. Enter the number of coupons or vouchers you'd like to print.
  3. Select Print Now.
  4. Give them to your patients with their prescription.

Who can request samples?

Only qualified physicians can sign to receive medication samples (using smart fax forms printed through the Sample Center). However, members of your staff (such as a sample coordinator) may assist in the process, just as they would in managing traditionally distributed orders.

Sample Request confirmation

You will receive an email confirmation whenever you successfully submit a sample request. Note that completing a request requires you to print, sign, and fax in the form, or sign on your mobile device.

Sample shipping speed

Medication samples typically arrive within 4 to 6 business days.

Service Benefits

Sample Center benefits

Most healthcare professionals agree that samples help them get patients on new treatments faster. Having samples in the office may help you more clearly explain how to take a product.

Benefits of Requesting samples online

Practices that request samples online appreciate the convenience of accessing leading prescription drugs and the ability to control the request process. Request samples as needed, when convenient for you. Four in five physicians surveyed expressed strong interest in requesting medication samples online.

Is the service free?

This service is free to qualified medical practices. There is no cost to request or receive medication samples. This is made possible by participating pharmaceutical manufacturers and powered by technology from SymmetryRx, LLC.

Your Account

Use of your NPI number

Your NPI number lets us determine which samples are available for you and allows us to verify that you're authorized to write prescriptions.

Use of your email address

Sample Center uses your email address only for the following purposes:

  • Providing confirmation that you have successfully activated your account
  • Providing confirmation that you have successfully placed a sample request
  • Notifying you when new samples are available

Your email address and associated information will not be used for any purpose other than providing this service to you.

Discontinue your participation

You may de-activate your account at any time by emailing us at or by calling our toll-free customer support hotline at (866) 363-3726.

Records of previous sample Requests

The Sample Request History link provides an easy way to review your previous transactions.

  • If you wish to reprint a request form, click the request number and click Reprint Fax
  • If you are resending a request (not requesting again), the requesting physician must sign the request summary document and fax it to the number printed at the bottom of the form

Sample Availability

My available samples

To find out what samples are available, simply sign in to your account. Available samples are displayed in your Sample Center.

Notification of additional samples

We'll send you an email whenever new samples are available.

Sample supply replenishment

The Available Samples Summary link shows the date that your inventory of samples will be replenished.

Expanding our sample roster

New brands are periodically added to this service. If you'd like to recommend that a brand be added, let us know by emailing us at

Recurring Requests

About Recurring Requests

A Recurring Request is a convenient way get samples delivered to your office on a regular basis.

Once you've set up a Recurring Request, we'll fax you an order form each time additional allocations of the brand are available to you; typically on a weekly, bi-monthly, or monthly basis.

You simply need to

  1. Sign and date it.
  2. Fill in your state medical license number.
  3. Indicate your professional designation.
  4. Fax it back to the number printed on the form.

Your samples will be shipped to you once the completed form has been received.

Set up a Recurring Request

Brands that are eligible for Recurring Requests are listed under the Recurring Request section of the Sample Request page. To create a Recurring Request for a brand, click the checkbox next to the brand you're interested in.

Brand eligibility for Recurring Requests

Brand eligibility for the Recurring Request service is determined by the brand manufacturer. Recurring Requests are limited to orders that are fulfilled via fax order.

Managing Recurring Requests

Click the Manage Recurring Requests link under My Account. Select Manage Recurring Requests to change or cancel. Canceling a Recurring Request does not prevent you from creating a new Recurring Request for the same brand in the future. However, you may only have one Recurring Request for a particular brand at any given time.