Please email the following information to
president@eleganceinfo.com
to ensure proper delivery of your samples.


NAME
PROFESSIONAL DESIGNATION (ie. MD, PA-C, FNP, RN, MA, etc.)
CLINIC/COMPANY NAME
ADDRESS WHERE YOU WANT TO RECEIVE THE SAMPLES
PHONE / FAX NUMBER (optional)
NUMBER OF SAMPLES REQUESTED
WHERE DID YOU HEAR ABOUT US?
ANY ADDITIONAL INFORMATION YOU'D LIKE TO ADD