Sample/Sales Representative Request

The Sample and Sales Representative request form is a resource for Healthcare Professionals. Please complete the form below and submit it to Eli Lilly and Company to request samples and/or contact by a sales representative.

Samples may only be requested for use by Prescribing Healthcare Professionals.

Fields with (*) are mandatory

For more information about Lilly's privacy practice, please view the Privacy Statement.

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If you need information about a Lilly product or want to report an Adverse Event or Product Complaint, you may call us.

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