800.879.4755  UNITED STATES
913.217.7160 INTERNATIONAL

Sample Request Form
* PROFESSIONAL USE ONLY*
Please enter information, print, sign, then mail or fax form to:
Nephro-Tech, Inc., P.O. Box 16106, Shawnee, KS 66203
Fax: 913-217-7200
Please Note an Asterick (*) Denotes a Required Field
*Licensed Practitioner's Name Company Name
*Mailing Address
*City   *State: *Zip Code
*Phone Number Fax Number
*Place an X by the products you would like
NephPlex® Rx RenaPlex®D MagneBind® 300 MagneBind® 400 Rx
*Licensed Practitioner's Signature *State License #
Complete the Information Below if Samples are to be Sent to a Dialysis Unit
Company Name *Contact Name
*Mailing Address
*City   *State: *Zip Code
*Phone Number Fax Number
Number of Patients Hemo: PD:
FOR NEPHRO-TECH, INC. USE ONLY - DO NOT WRITE BELOW
Date Request Recieved Date Samples Shipped
Authorized By Form #
NephPlex® Rx RenaPlex®D MagneBind® 300 MagneBind® 400 Rx


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