SAMPLE REQUEST FORM
FOR DIABETES HEALTH PROFESSIONALS

As we all know, hypoglycemia can happen anytime, anywhere. We at Dex4 believe that hypoglycemia preparation, education and awareness are very important. Helpful educational support is available in the Learning Center to learn more about hypoglycemia, how to treat this condition, and how Dex4 fast-acting glucose works faster than candy, cola and juice. Dex4 is happy to support diabetes educators with free samples of Dex4 fast-acting glucose products and hypoglycemia educational materials. If you are affiliated with a diabetes clinic or hospital please complete the form below:

Requestor Details Name:  
Hospital/ Clinic/ Company:  
Department:  
Department Director:  
Phone:  
E-Mail:  
Fax:  
Diabetes Class Information Number of diabetes educators (CDE, Dieticians, etc.) at this location:  

Average number of patients with diabetes educated weekly:  

Average number of NEWLY diagnosed patients seen weekly:  

When educating on hypoglycemia, how long (minutes) do you typically discuss?:  

Do you travel to different locations to educate patients with diabetes?: Or

If you qualify, would you be interested in receiving a FREE Dex4 Hypoglycemia Educator Kit?: Or
Shipping Address (Please allow 3 to 4 weeks for delivery) Delivery Date:  
Attn:  
Hospital/ Clinic/ Company:  
Address:  
City:   State:  
Zip:  
Phone  
E-Mail:  
Fax:  
Has your address changed within the last 6 months?: Or
Samples (Enter desired amount) **Please note that depending on inventory availability, requested quantities may be reduced.**

Glucose Pouch Packs
Glucose 50ct Bottles
Glucose 10ct Tablets
Glucose 2oz Gel Tubes
Glucose 2oz Liquid Bottles

On behalf of the Dex4 team, we thank you for educating and raising awareness of hypoglycemia and emphasizing the importance of always being prepared with Dex4 fast-acting glucose products. For more information to encourage patients and children about hypoglycemia, Dex4 glucose products and where to buy, please visit Dex4.com. Please note we will do our best to honor all requests; however, do to the fluctuation of sample inventories we may find it necessary to adjust/limit the samples you receive.