Yes, please send me 6 bottles of EVOXAC (cevimeline HCl) 30 mg capsules (30 count each).

Thank you for your interest in receiving samples of EVOXAC. You are taking an important step in providing your patients with an effective treatment option for their dry-mouth symptoms associated with Sjögren’s syndrome.

Here's how to order EVOXAC samples for your patients:

Complete the form below, Print, Sign, Fax the signed form to 888-837-0290

*Required Fields

*Name
*Address
 Address
*City
*State
*ZIP Code
*Professional Designation
*Phone
*Fax
*Email
*Request Datemm/dd/yy
*State License #

You must remember to sign this form before faxing
it to 888-837-0290. Please allow 3-4 weeks for sample delivery.

Sign Here

My signature certifies that I am a licensed practitioner with the ability to request samples of the above products in the above state. I have requested the indicated samples for the medical needs of my patients. Furthermore, I understand that this product cannot be sold, traded, bartered, returned for credit or utilized to seek or obtain reimbursement.

As a Nurse Practitioner or Physician Assistant, I attest that I meet all appropriate state-level sampling conditions, including but not limited to collaborative or supervisory agreements with a physician.

Please note that this sample program is subject to eligibility rules. You will be notified if you are not eligible due to federal or state requirements or company policies.

By completing and faxing this sample request, you are agreeing to receive future offers and information about EVOXAC and related health information.

The information you provide may be used to send you health-related materials and to develop products, services, and programs. Daiichi Sankyo, Inc. or third parties working on our behalf will not sell or rent personal information. For more information on how Daiichi Sankyo, Inc., is committed to protecting your privacy, please read our Terms of Use and Privacy Policy at www.EVOXAC.com.

Samples distributed by Phoenix Marketing Group, L.L.C.

Daiichi Sankyo

Manufactured for Daiichi Sankyo, Inc.,
Parsippany, NJ.

This information is intended for U.S. residents only.
© 2010 Daiichi Sankyo, Inc.
DSEV10000206 6/10

DCSIMG