Thank you for requesting samples from PharmaDerm, a division of Fougera Pharmaceuticals Incorporated. Please complete the below information and fax the form to 1-877-533-9154. Incomplete and duplicate requests cannot be processed and you MUST check the box to the right of any item(s) you would like to request. Properly completed request forms will be processed within 2-3 business days and delivered overnight via UPS.PharmaDerm will only fulfill 1 order per month through this program’s expiration date of 3/31/2022. For order status inquiry, please call 1-800-821-1374.
Licensed Practitioner’s Last Name, First Name
State License Number
Print exactly as it
appears on the certificate. This number is required to allow you to receive samples.
Address (No PO Boxes)
City, State, ZIP Code
Form # SAN0000000Source code SANFX27904
Sample and Material Request (please check boxes to confirm items requested):
KERYDIN®(tavaborole)Topical Solution 5%
Each unit contains (6) 4 mL samples
SIGNATURE REQUIRED.Original ink-written
signature of licensed practitioner required. (No signature stamps)
My signature certifies that
I am a licensed practitioner eligible to request and receive these samples. These samples are being requested
for the medical needs of my patients and are not intended for and are prohibited from sale, trade, barter, and
return for credit. I understand that I may not seek or accept any reimbursement for these samples as I will
not incur any cost in relation to them. I understand that PharmaDerm, a division of Fougera Pharmaceuticals
Incorporated will mail these samples directly to my office and that I will be required by federal law to sign
an acknowledgment for delivery. For Ohio practitioners only: I attest that I have an active Terminal
Distributor of Dangerous Drugs (TDDD) license at this location or that I am exempt from TDDD licensure. Under
Ohio law, a prescriber who possesses dangerous drugs must have a TDDD license unless exempt as a sole
proprietor, sole shareholder, or dentist. TDDD license requirements can be found at:
As per federal requirements, incomplete requests and duplicate requests cannot be processed.
KERYDIN®is a registered trademark of Anacor Pharmaceuticals, Inc.