Request Samples

I am a healthcare professional requesting samples for my patient
*
- I have my patient's permission to provide their information to Kate Farms.
Your Name*
First Last
Office Phone*
Fax
Email*
Institution Name*
Clinic, facility or hospital name
Institution Address*
Street Address City State ZIP Code
Area of Specialty*
What patient population do you work with most?*
Are most of your patients inpatient or outpatient?*
Credential Type*
Credential (NPI, License, or CDR)*
By including this number, you are representing that the patient named and that the sample requested is appropriate for this patient.
How did you hear about Kate Farms?*
Preferred DME or Infusion Company?*
Other DME or Infusion Company*
Patient Information
Our Customer Care team can help your patient obtain the necessary paperwork for coverage and find an in-network partner who can supply them. They do NOT provide clinical advice.
If you’d prefer Customer Care does not contact your patient, please indicate below.
- No thank you, I’ll follow up with my patient and assist them with the insurance process. (If you select this option, we will use the patient contact information below for shipping purposes only.)
- Yes please! I’d love for Customer Care to help my patient with the next steps.
Patient's Name*
First Last
Patient's Address*
Street Address City State ZIP Code
Patient's Phone*
Patient's Email
Prescribing Physician*
Patient's Payment Method*
How will this patient be obtaining the formula?*
If other, please explain.
Primary use of formula*
Formula to sample*
Please choose the product you'd like to sample.
Formula to sample*
Please choose the product you'd like to sample.
Did the patient request Kate Farms?*
- Yes
- No
What diagnosis requires the patient to need enteral formula?
If other, please explain.
What enteral formula is the patient currently using?
If patient is changing to Kate Farms, why?
How many calories will the patient need per day from formula?
Patient's Current DME*
*
- I have read and understand the Terms & Conditions of the Kate Farms Sample Program.

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Healthcare Professional Patient Sample Request

I am a healthcare professional requesting samples for my patient

Patient Information

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Wholesale

Insurance