Product Sample Request Form

Samples are limited to one unit per product, with a maximum of 4 products per request.
Reason for Sample Request*
IMD Type*
Patient Full Name*
Patient Address Line 1*
Patient Address Line 2
Town*
Postcode*
Country*
Patient Telephone Number (Required For Delivery)*
Patient Email Address*
Dieitian Full Name*
Dieitian Full Hospital Name*
How Did You Hear About Us?*
metaX XPhe jump & XPhe minis Protein Substitute Samples Required: --- (For patients with PKU and HyperPhe only (XPhe jump suitable from 3 years of age / XPhe minis suitable from 7 years of age))
XPhe Jump Wild Berry 10

Sample
XPhe Jump Neutral 10

Sample
XPhe Jump Cola 10

Sample
XPhe Jump Orange 10

Sample
XPhe Jump Vanilla 10

Sample
XPhe Jump Tropical Fruit 10

Sample
XPhe Jump Cola 20

Sample
XPhe Jump Wild Berry 20

Sample
XPhe Jump Neutral 20

Sample
XPhe Jump Orange 20

Sample
XPhe Jump Vanilla 20

Sample
XPhe Jump Tropical Fruit 20

Sample
Low Protein Cous Cous
Low Protein Imitation Rice
Low Protein XPot All Day Scramble
Low Protein XPot Beef and Tomato
Low Protein XPot Chip Shop Curry
Low Protein XPot Rogan Curry
Low Protein Mac Pot Cheese
Low Protein Mac Pot Tomato
Low Protein Potato Pot Onion & Crouton
Low Protein Potato Pot Sausage & Crouton
Low Protein Potato Pot Bacon, Cabbage & Crouton
Low Protein Fresh Baked White Sliced Bread
Low Protein Fresh Baked White Bread Buns
Low Protein Fresh Baked Fruit Loaf
Low Protein Farmhouse Loaf
Low Protein Snax - Salt and Vinegar
Low Protein Snax - Cheese and Onion
Low Protein Snax - Jalapeno Flavour
Low Protein Snax - Salt and Vinegar
Low Protein Burger Mix Chicken Flavour
Low Protein Burger Mix Original Flavour
Low Protein Sausage Mix Original Flavour
Low Protein Hot Breakfast Original Flavour
Low Protein Hot Breakfast Banana Flavour
Low Protein Hot Breakfast Chocolate Flavour
Low Protein Hot Breakfast Apple & Cinnamon
Low Protein Chocolate Cereal
Low Protein Pasta in Sauce - Tomato, Pepper & Herb
Low Protein Pasta in Sauce - Cheese & Broccoli
Low Protein Breakfast Bar - Banana Flavour
Low Protein Breakfast Bar - Apple & Cinnamon Flavour
Low Protein Breakfast Bar - Cranberry Flavour
Low Protein Breakfast Bar - Chocolate & Cranberry Flavour
Total Selections
Date of Request

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Date
I consent for Firstplay to contact me about my sample request:*
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Total Low Protein Items Selected
Should be Empty:

Samples are limited to one unit per product, with a maximum of 4 products per request.