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Vitaflo USA Sample Request

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Sample Information

Person Requesting Sample

Shipping Information

*please note, we do not ship to P.O. Box Addresses

Medical Information

We ask for your Healthcare Professional information since our products are categorized by the FDA and will require authorization prior to shipping.

Is Patient currently attending clinic
Would you like to have a Virtual Taste Test with a Vitaflo Territory Manager*?
*Pending RD approval.  We will contact your RD for approval.

Privacy Statement & Authorization to Share Information:
Your privacy is important to Vitaflo USA, LLC (Vitaflo). Personal information collected by Vitaflo may be shared with Vitaflo’s affiliates, agents and contractors as well as other outside organizations (including healthcare providers, health plans and other product and service providers) to help provide patients with reimbursement support, including benefit verification, prior authorization and other reimbursement services. Additionally, Vitaflo and its affiliates and agents may use this information to contact patients about Vitaflo and its products and services. By submitting this information, I agree that Vitaflo and the outside organizations with which Vitaflo shares this information may contact me at any of the telephone numbers, including cell phone numbers, or email addresses provided. Vitaflo will not sell or rent personal information to others.

Click here to review our Terms and Conditions