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Educators Request Form


Dex4 Samples for Diabetes Educators

We appreciate your help in building awareness and understanding of hypoglycemia, and emphasizing the importance of always being prepared with Dex4 Fast-Acting Glucose products. With that in mind, as a diabetes educator, you may want to submit the form below for samples of Dex4.

If you are a Diabetes Educator who is affiliated with a diabetes clinic or hospital, and using your Dex4 samples for patient education, please complete the form below. We are unable to supply hospital emergency rooms and clinical research studies with free samples so please contact wholesalers such as McKesson, Cardinal and AmerisourceBergen to purchase Dex4 Fast-Acting Glucose products.

All fields marked(*) are required to receive free product samples.
Please note: We do not ship to P.O. boxes

Requestor Details

*First Name:
*Last Name:
Department Director:
- - - Ext. (this MUST be a valid number)
*Email Address:
*Confirm Email Address:
- -

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 about hypoglycemia, how many minutes do you typically discuss it?*
Do you travel to different locations to educate patients with diabetes?*

Shipping Address
(Please allow 4 to 6 weeks for delivery)

* Delivery Date 
*Shipping Address:
*Postal Code:
- - - Ext.
- -
Has your address changed within the last 6 months?