Sample Request for Health Professionals

Research shows patients and diabetes educators alike prefer Clickfine's click-on pen needles over traditional screw-on pen needles. Try the click-on feature 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 marked with an asterisk (*) are required.

Requester Information

* First Name:

Middle Initial:

* Last Name:

* Hospital/Clinic/Company:

* Department:

* Department Director:

* Phone Number: () —

Fax Number: () —

* Email Address:

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

* Delivery Date: / /

* Attn:

* Hospital/Clinic/Company:

* Address:

Address:

* City:

* State:

* Zip Code:

* Phone Number: () —

Fax Number: () —

* Email Address:

* 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

QUICK LINKS

Resource Center for Health Professionals

Always Be Prepared with Dex4 Fast Acting Glucose

Tips

Carry Your Diabetes Supplies With You
When you're on the go, the last thing you want to worry about is your diabetes supplies. Put your mind at ease and use a compact diabetes case to conveniently carry your supplies and protect them from damage. Include your diabetes pens, pen needles, glucose meter, test strips, lancing device, lancets, alcohol swabs and glucose tablets to correct a low.

Where to Buy Clickfine

Visit a store near you to find Clickfine Pen Needles and co-branded pen needles made with Clickfine technology.

At Your Fingertips

You can find useful information at our Learning Center. Check out and download our Injection Techniques and Tips.