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Sign instantly with eSignature. No need to print or fax. Simply re-enter your username and password to sign electronically.
I understand that my electronic signature will be equivalent to a legally binding handwritten signature.
I certify that I am a licensed prescriber, eligible to request and receive the drug samples listed in the quantities indicated. I am also confirming that these samples will be used exclusively for the medical treatment of my patients in conformity with all relevant state and/or local prescribing and dispensing requirements. My signature will also serve as confirmation of my receipt of these medications, if delivered by a company representative, or my intention to acknowledge them upon delivery to my medical office if shipped via common carrier. I understand that these samples cannot be sold, traded, bartered returned for credit or utilized to seek or obtain reimbursement.
If you are an Ohio licensed health professional - the Ohio Board of Pharmacy requires Terminal Distributors of Dangerous Drugs to obtain a TDDD license prior to accepting pharmaceutical samples, unless subject to the exceptions listed in ORC 4729.541., including Section (A)(1): a licensed health professional authorized to prescribe drugs. More information on this requirement can be found at http://www.pharmacy.ohio.gov/PrescriberTDDD. In signing this request, Ohio health professionals attest they are either in compliance with or exempt from the state's TDDD licensure requirement.
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