ORDER QUANTITY

□ 6 Units □ 12 Units (Each sample contains 1 unit with 4 softgels)

Practitioner’s Full Name ____________________________________________ Medical Specialty __________________________

Physical Address _______________________________________ City ______________________ ST ________ ZIP _________

(Sorry, No PO Boxes)

Office Phone _________________________________________________________ Ext. ________________________________

Office Contact _____________________________________________________ Phone _____________________ Ext. ________

Practitioner’s Signature ____________________________ Date _______________ State & License No. ________________

Sample Authorization: By signing this FoletOneTM Sample Request Form, I certify that I am a Practitioner who can legally prescribe in the U.S. I am requesting the above samples from Pronova Corporation for the medical requirements of my patients.

INSTRUCTIONS1. Please fill out completely. Incomplete orders cannot be filled.

2. Provide an original signature and license number (no stamps permitted).

3. FAX THIS SHEET WITH THE COMPLETED INFORMATION TO PRONOVA CORPORATION AT: 305.489.4665

4. To request additional information, please contact your local Pronova representative or contactus toll free at: 866.703.3508

Note: Please fill in all the requested information. According to federal law, no drug samples can be sent if any information is missing from this form.

X

Order Number

5000 SW 75th Avenue, Suite 113. Miami, Florida 33155Toll Free: 866.703.3508 | Fax: 305.489.4665

‡ Quatrefolic® under exclusive license from Gnosis, S.p.A covered by U.S. Patent No. 7,947,662 and patents pending PCT/EP2008/052037 and PCT/EP2008/052034‡‡ Ferrochel® and TRAACS® are registered trademarks of Albion Laboratories, Inc., covered by U.S. Patents 6,716,814 and 7,838,042.

Vitamin C (as calcium ascorbate)....................... 18 mg

Vitamin D (as cholecalciferol)............................ 250 IU

Vitamin E (as d-alpha tocopheryl acetate)............ 15 IU

Vitamin B6 (as pyridoxine HCl).......................... 30 mg

Folate (as 1.85 mg (6S)-5.................................... 1 mg-methyltetrahydrofolate -Quatrefolic®) ‡

Vitamin B12 (as cyanocobalamin).................... 15 mcg

Iron (as carbonyl iron -Ferronyl® and ferrous.... 38 mg bis-glycinate chelate -Ferrochel®) ‡‡

Zinc (as zinc oxide)............................................ 20 mg

Magnesium (as magnesium oxide)..................... 15 mg

Docusate Sodium............................................... 25 mg

DHA (Docosahexaenoic Acid from Algal Oil).... 225 mg

Tel. (714) 847-7885

Thomas Smith, M.D7154 Edinger Ave.

Huntington Beach, CA 92647-3505

NAME AGE

ADDRESS DATE

Maria Perez

Folet Onesig: 1 qd

# 30Refill