Remi Prac Request

Welcome to the Remifemin professional sample request. This sample kit is available to medical professionals only. Each kit contains (12) Remifemin 20-day supply samples and brochures for you to distribute to your perimenopausal and menopausal patients.

Please take a moment to fill out the information below.

Thank you for your interest in Remifemin.

*Practitioner Name:

*Clinic Name:

*Is this a Women's Health focused clinic?

Yes
No

*Average number of peri & menopausal patients seen per week?

1-10
11-25
25-50
50+

*Contact Name:

*Street Address:

*City:

*State:

*Zip Code:

*Office Phone:

Office Fax:

*Email Address:

Website:

Please Note: Limited to one kit per professional every 30 days.