Product Sample Request Form

Samples are limited to one unit per product, with a maximum of 4 products per request. (Excluding XPhe minis & XPhe jump protein substitutes)
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
XPhe Jump Neutral 10
XPhe Jump Cola 10
XPhe Jump Orange 10
XPhe Jump Vanilla 10
XPhe Jump Tropical 10
XPhe Jump Cola 20
XPhe Jump Wild Berry 20
XPhe Jump Neutral 20
XPhe Jump Orange 20
XPhe Jump Vanilla 20
XPhe Jump Tropical 20
XPhe Minis Tablets
Promin LP Cous Cous
Promin LP Imitation Rice
Promin LP XPot All Day Scramble
Promin LP XPot Beef & Tomato
Promin LP XPot Chip Shop Curry
Promin LP XPot Rogan Style Curry
Promin LP Mac Pot Cheese
Promin LP Mac Pot Tomato
Promin LP Potato Pot Onion & Croutons
Promin LP Potato Pot Sausage & Croutons
Promin LP Potato Pot Bacon, Cabbage & Croutons
Promin LP Fresh Baked White Sliced Bread
Promin LP Fresh Baked Bread Buns
Promin LP Fruit Loaf
Promin LP Farmhouse Loaf
Promin LP Snax Salt & Vinegar
Promin LP Snax Cheese & Onion
Promin LP Snax Jalapeno
Promin LP Snax Ready Salted
Promin LP Burger Mix Chicken
Promin LP Burger Mix Original
Promin LP Sausage Mix Original
Promin LP Hot Breakfast Original
Promin LP Hot Breakfast Banana
Promin LP Hot Breakfast Chocolate
Promin LP Hot Breakfast Apple & Cinnamon
Promin LP Cereal Chocolate
Promin LP Pasta in Sauce Tomato, Pepper & Herb
Promin LP Pasta in Sauce Cheese & Broccoli
Promin LP Breakfast Bar Banana
Promin LP Breakfast Bar Apple & Cinnamon
Promin LP Breakfast Bar Cranberry
Promin LP Breakfast Bar Chocolate & Cranberry
Total Selections
Date of Request

MonthDayYear
Date
I consent for Firstplay to contact me about my sample request:
I consent for Firstplay to contact me via:
Total Low Protein Items Selected
Don't forget you can only order 4 items maximum
Should be Empty:

Samples are limited to one unit per product, with a maximum of 4 products per request. (Excluding XPhe minis & XPhe jump protein substitutes)