THIS FORM IS CLOSED
Please contact your sales rep for receiving our new collateral assets (Fall 2025). You may still submit your name & info for us to follow up with you.
Recipient Information
If multiple recipients need different collateral amounts from each other, please submit a separate form for each recipient. Otherwise, each address listed will receive identical packages.
Recipient Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Recipient Email
*
doctor@clinic.com
Company/Practice Name
*
First Date Facility Accepts Delivery
-
Month
-
Day
Year
Date
Supplies:
Please provide any other requests or notes in the "other information" section listed below.
Titration Guide QTY:
Please Select
1
2
3
4
5
10
Recommend 1 to 2 per physician in the practice.
Patient Low-T Screener QTY:
Please Select
1
5
10
50
Single sheets. Recommended quantity: 50.
Lab Timing Troubleshooting Guide QTY:
Please Select
1
2
3
4
5
6
7
8
9
10
Recommend 1 to 2 per physician in the practice.
Patient Trifold Brochure QTY:
Please Select
1
2
3
4
5
10
HCP Trifold Brochure QTY:
Please Select
Currently Unavailable.
Features pocket with folded KYZATREX Prescribing Information sheet. Recommended quantity: 1 to 2 per physician in the practice.
Patient Expectation QTY:
Please Select
Currently Unavailable
Aid for patients on what to expect when starting treatment.
Brochure Holder QTY:
Please Select
0
With Marius Pharmaceuticals logo on front.Recommended quantity: 1 per room displayed.
Pharmacy One Pager
Contains NPI/NCPDP, Phone & Fax number, etc of the mail-order pharmacy. (Note: EPIQ SCRIPTS requires enrollment).
Pharmacy:
Please Select
Pharmacy One Pager (Gift Health)
Pharmacy One Pager (Revive)
Pharmacy One Pager (DiRx)
Pharmacy One Pager (Epiq)
Pharmacy Quantity:
Please Select
5
10
50
100
150
Recommended quantity: 1 to 2 per physician in the practice.
Additional Pharmacy:
Please Select
Pharmacy One Pager (Gift Health)
Pharmacy One Pager (Revive)
Pharmacy One Pager (DiRx)
Pharmacy One Pager (Epiq)
Additional Pharmacy Quantity:
Please Select
5
10
50
100
150
Recommended quantity: 1 to 2 per physician in the practice
Tear Pad:
Discussion Points:
Please Select
1
2
3
4
5
6
7
8
9
10
25-sheets per pad.
Folder Option:
Folders QTY:
Please Select
1
2
3
4
5
10
25
Would you like the printed materials enclosed in a folder or have empty folders sent?
Enclose materials in a folder
Send empty folders with materials
No Folder
Large Format Prints
KYZATREX 18x24 Posters
Bottle Poster Quantity
Note: Posters will be shipped separate from other materials.
Grill Guy Poster Quantity
Note: Posters will be shipped separate from other materials.
Other Information/Requests:
Delivery:
UPS or FedEx Shipping will be used. Please NOTE ABOVE if a different service is required.
How many packages are going out?
Please Select
1
2
3
4
5
6
7
8
9
10
Address(es):
*
Please list the street address, city, state, and zip code in this box. For multiple packages, please put them in a list format. Example: - 4158 Pine Road Columbia, PA 16044
Address
*
Street Address
Suite Number
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Choose which representative has helped you, if any.
*
Please Select
Polly Sawyer
Brandon Keip
Vicky Behne
Lauren Callaghan
Paul Harris
Other
NONE
Any questions regarding shipments, please email us: info@kyzatrex.com
Submit
Clear/Rest Form
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