Sample Request Form

NOTE : Free Samples of Dermazinc™ spray compounded with 64 mg Micronized Betamethasone Diproprionate USP will only be sent to the physical address of a Medical Practice, or hospital and will not be sent to a PO Box.

Designation:

Other Designation:

First name:

Last name:

Medical practice name:

Medical practice address:

City:

State:

Zip code:

DEA / License #:

Phone number:

Email address:

How did you hear about us?

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Option box to receive future mailings:

*Indications: DermaZinc™ Spray/Drops/Cream compounded with Micronized Betamethasone Diproprionate USP is a short-term topical treatment for the treatment of moderate to severe cases of eczema, psoriasis, seborrheic dermatitis, atopic dermatitis and dandruff, including itching, redness, irritation, scaling and flaking. Apply to affected area two times a day for a maximum of two weeks. Maintain results by applying DermaZinc™ Spray/Drops/Cream (OTC) to affected areas two times a day, three days a week. If condition returns, DermaZinc™ with Micronized Betamethasone Diproprionate USP can be used again with the same safe and effective results. DermaZinc™ OTC Spray/Drops/Cream/Shampoo/Soap: FOr relief of itching, redness, irritation, scaling and flaking associated with mild to moderate cases of eczema, seborrheic dermatitis, atopic dermatitis and dandruff. Apply to affected area two times a day until condition improves. Maintain results by applying two times a day - three days a week. Micronized Betamethasone Diproprionate USP must be used when preparing this compound.