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Patient Profile Information

*First Name:
*Last Name:
*Email:
*Relationship to the Patient
*How did you hear about the sample program:
Select the formula samples you’d like to receive:
KetoCal® 4:1 LQ
KetoCal® 4:1 LQ
Chocolate
Unflavored
Vanilla
KetoCal® 4:1 Powder
KetoCal® 4:1 Powder
KetoCal® 3:1
KetoCal® 3:1
KetoCal® 2.5:1 LQ
KetoCal® 2.5:1 LQ

Shipping Information


Note: We cannot ship to P.O. Box addresses      

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*Phone: (Format: xxx-xxx-xxxx)

Healthcare Professional Information

KetoCal® products are categorized for use under medical supervision. To comply with the highest standards recognized by federal law, we are required to obtain your clinician’s approval before shipping.

*Ketogenic Clinician Full Name:
*In which state is your clinic?:
*Dietitian Email Address   
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Terms Acceptance
Nutricia seeks authorization for all samples by a healthcare professional prior to shipping. I agree to sample authorization and accept the Terms of Use of this website.
   

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