Consumer Sample Requst Form

Research shows people with diabetes prefer Clickfine's click-on pen needles over traditional screw-on pen needles. See why — try it for yourself!

Please allow 4-6 weeks for delivery. The offer is valid while supplies last. Available in the U.S. where permitted by law (excludes Delaware, Massachusetts, New Jersey and Pennsylvania). Your information is safe with us; view the Clickfine® Privacy Policy.

Fields with a "*" are required.

Your Information

Name: (*) First Last Middle Initial
Address:
Street Address (*)

Address Line 2

City (*)

State (*)

Zip Code (*)
Email: (*)
Phone: (*) - (###) - ### ####

Questions

What best describes you? (*)
What is your usual method of injecting? (*)
If you use insulin syringes, what brand do you use most often? (*)
If you use pen needles, what brand do you use most often? (*)
How are your insulin syringes or pen needles paid for? (*)

Sample Pack Desired:

Please tell us which pen needle you would like to try : (*)
(Note: please consult with your health professional before changing pen needle lengths.)
Clickfine Pen Needle Sample Pack 6mm, 31G Clickfine Pen Needle Sample Pack 8mm, 31G

Your information is safe with us. CanAm Care, LLC, the marketers of Clickfine, will not sell or rent your information to any third parties or outside mailing lists. By checking Yes in the box above, I indicate my understanding that the information I provide may be used by CanAm Care, LLC, its affiliates, and the business companies working with the company to provide me with information about diabetes, related conditions, and products; and to develop products and services concerning diabetes, which may include market research. To be removed from our mailing list, please call 1-800-461-7448.

Sample Request for People with Diabetes