Information for Doctors

How to Get More Sample Packets

Thank you for trying the sample packets of Skin MD Natural.
To receive more please complete the following sample request form...

Name of Doctor(s)

1. Primary Doctor *:

Your Name *:

Your Position *:

Name of Practice *:

Type of Practice *:

Dermatology
Allergy
General Practice
Internal Medicine
OBGYN
Other

Please, type in:*

Address of Practice *:

City *:

State/Province *:

Zip Code *:

Phone Number of Practice *:

Fax Number of Practice *:

Your email address *:

Do you prefer to be contacted by *:

email
phone
fax

Are you primarily interested in more samples: *:

to be used for doctors and staff
to be used to hand out to patients

If you are going to pass out samples to patients they are going to want to know where to purchase it.

Do you wish to sell Skin MD Natural in your practice? *:

yes
no

If no, which pharmacy/drug store(s) would be most convenient for your patients to purchase it at?

We will contact these pharmacies and when they order we will notify you so you can tell your patients where to purchase
it locally.

1. Name of Pharmacy : Phone number :
2. Name of Pharmacy: Phone number:
3. Name of Pharmacy: Phone number:
4. Name of Pharmacy: Phone number:
5. Name of Pharmacy: Phone number:

It will help us make Skin MD Natural™ available locally if you tell these pharmacies that you are passing out samples of Skin MD Natural™ to your patients and they need a place to purchase it locally.

If you do this we will send you a 4-oz size bottle of Skin MD Natural™ at no charge.
Go to www.SkinMDNatural.com/forms/free-bottle.php.
This web address will automatically be emailed to you as a reminder.

We will send you a 4-oz bottle of Skin MD Natural for each pharmacy you speak to.

Anything you wish to
communicate to us?: