Shipper Request Form

Clinic Name*

Main Contact Name*

Main Contact Telephone*

Main Contact Email*

Street*

Suite/Unit/Floor/Etc

City*

Postcode*

Country*—Please choose an option—DenmarkIrelandItalyMexicoNorthern IrelandNorwayUnited Arab EmiratesUnited KingdomUnited States
If outside UK or Ireland, please answer question 4.

Next Available DateYes

Or Request a Date

Next Available DateYes

Or Request a Date

Clinic Opening/Closing Times and Latest Time Available*

Number of Samples in Shipment*

Disclaimer: A return address, commercial invoice, and return cable tie will be included inside the "mushroom container". Please keep these safe until you are ready to return the dry shipper. Load the samples, fix the new cable tie on the metal butterfly clasp, attach the Examen return address label and two printed copies of the commercial invoice to the outside of the "mushroom container."

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I accept*