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PR Kit Order Request

Use this form to request samples/PR kits for your clinic. Please share accurate delivery and contact details.

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Your full name ^*

Name ^*

Last Name

Phone Number

Company

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Designation ^*

e.g., Consultant Gynaecologist, Obstetrician, Medical Officer

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Please fill the following ^*

Email ^*

Phone Number ^*

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Delivery address

Include street, city, state, postal code, and landmark (if any).

Address

Address line 2

City

State

Zip

Country

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Preferred delivery time

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Select the PR kit/sample items you want (as per shared sample PR kit) ^*

Choose all that apply.

Sample PR Kit (Complete)

Product Sample(s)

Brochure / Leaflets

Patient Education Material

Doctor’s Desk Standee

Poster / Clinic Display Material

Price List / Catalog

Other

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If you selected specific product sample(s), list product names and required quantities

Example: Product A – 10 units, Product B – 5 units.

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Total number of kits/samples required ^*

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Is this your first request? ^*

Yes

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Any special instructions for packing/delivery

e.g., call before delivery, reception hours, alternate contact.

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Do you agree that the items are for professional sampling/clinic use only (not for resale)? ^*

Yes, I agree

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Signature

Sign to confirm the request details.

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Request submitted

Thank you. We’ll review your order request and contact you if we need any clarification.

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