Healthcare Sample Requst Form

Research shows patients and diabetes educators alike prefer Clickfine's click-on pen needles over traditional screw-on pen needles. See what all the fuss, and attraction, is about and try it for yourself. Better yet, give your patients a chance to try them too!

Please allow 4-6 weeks for delivery. Quantities shipped may be adjusted as necessary, and the offer is valid while supplies last. Available to qualified health professionals in the U.S. only. Your information is safe with us; view the Clickfine® Privacy Policy.

Fields with a "*" are required.

Requester Details

Name: (*) First Last Middle Initial
Hospital/Clinic/Company: (*)
Department: (*)
Department Director: (*)
Phone: (*) - (###) - ### ####
Fax: - (###) - ### ####
Email: (*)

Diabetes Class Information

Number of diabetes educators (CDE, etc.) at this location: (*)
Average number of patients with diabetes educated weekly: (*)
Average number of insulin requiring patients educated weekly: (*)
Average number of insulin requiring patients initiated (weekly) on: (*) Pens: Syringes: Pumps:
Average number of patients initiated on Byetta and Symlin weekly: (*)

Shipping Address

We only ship to business addresses (please allow 4 to 6 weeks for delivery)
Delivery Date: (*) / MM / DD YYYY
Attn: (*)
Hospital/Clinic/Company: (*)
Address:
Street Address (*)

Address Line 2

City (*)

State (*)

Zip Code (*)
Phone: (*) - (###) - ### ####
Fax: - (###) - ### ####
Email: (*)
Has your address changed within the last 6 months? (*) Yes No

Samples (Enter desired amount)

Please note that depending on inventory availability, requested quantities may be adjusted.
Clickfine Pen Needle Sample Packs 6mm, 31G
Clickfine Pen Needle Sample Packs, 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 Health Professionals