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Request a Sample

Fields marked with an “ * ” (asterisk) are mandatory.

Are you a Metabolic Dietitian?
*Select Your Metabolic Condition:

Select the formula samples you’d like to receive:


Lunch Tote - <b>LIMITED TIME OFFER!</b>
Lunch Tote - LIMITED TIME OFFER!


PhenylAde® GMP Drink Mix
PhenylAde® GMP Drink Mix
Vanilla
Original flavor


PhenylAde® GMP Mix-In
PhenylAde® GMP Mix-In


PKU Periflex® Early Years
PKU Periflex® Early Years


Periflex® Junior Plus
Periflex® Junior Plus
Plain
Berry
Orange
Vanilla


Periflex® LQ
Periflex® LQ
Berry Crème
Orange Crème


PKU Lophlex® LQ
PKU Lophlex® LQ
Mixed Berry Blast
Juicy Orange
Juicy Tropical


PhenylAde® Essential Drink Mix
PhenylAde® Essential Drink Mix
Orange Creme
Strawberry
Unflavored
Vanilla
Chocolate


PhenylAde®60 Drink Mix
PhenylAde®60 Drink Mix
Unflavored
Vanilla


Periflex® Advance
Periflex® Advance
Unflavored
Orange


Lophlex® Powder
Lophlex® Powder
Berry
Orange


Phlexy-10™ Tablets
Phlexy-10™ Tablets


PhenylAde® MTE Amino Acid Blend
PhenylAde® MTE Amino Acid Blend
Unflavored MTE


PhenylAde® PheBLOC
PhenylAde® PheBLOC
Tablets
Powder


Guide To Getting Back On The PKU Diet
Guide To Getting Back On The PKU Diet
*What is your current main formula?:

Patient Profile information

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*First Name:
*Last Name:
*Email:
*Relationship to the Patient
*How did you hear about the sample program:
Comments or Special Requests:

Shipping Information:

Note: We cannot ship to P.O. Box addresses
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*First Name:
*Last Name:
*Phone: (Format: xxx-xxx-xxxx)
*Street Address:
Address2:
*City:
*Country:
*State/Province:
*Zip Code:

Metabolic Healthcare Professional Information

We ask for your Dietitian information since our products are categorized for use under medical supervision. This means that certain Dietitian information be gathered by us so we comply with the highest standards recognized by federal law.

*Dietitian Name:
*In which state is your clinic?:
*Clinic Name:
Dietitian Phone Number:    (Format: xxx-xxx-xxxx)
Create an account to save your information and time.

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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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