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Sample Request Form If you would like to try a Delasco Electrolite, please provide the information below. You should receive your FREE sample in 2 - 4 weeks. Note: Federal law restricts the sale of this device to licensed physicians. Electrolites are intended for dermatologic purposes only. required fields are bold Physician's Name: Institution or Practice Name: Medical Specialty: Allergy/Immunology Cardiology Chiropractor Cosmetic Surgery Dentistry Dermatology Endocrinology Family Practitioner Gastroenterology General Practitioner Obstetrics/Gynecology Infectious Disease Internal Medicine Ophthamology Oral Maxillofacial Surgery Orthopedics Otolaryngology Pediatrician Plastic Surgery Podiatry Psychiatry Surgery Urology Veterinarian Medical Specialty Not Listed License Number: Address: City: State/Province: Country: Zip/Postal Code: Phone Number: Person Requesting: Email Address:

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