Provide your patients with the Most & Only!

Directions:

1. Download the Sample Request Form to your computer
   
   
2. Print your copy
   
   
3. Fill out all fields of the form
   
   
4. Personally sign and date the bottom of the form (no stamps allowed)
   
   
5. Fax the form to Xanodyne at (859) 371-6391

As with any prescription-strength product containing folic acid, omega-3 fatty acids, iron, or vitamins D and E, please adhere carefully to the recommended dosages. Folic acid may obscure the diagnosis of pernicious anemia. Supplementation with omega-3 fatty acids should be avoided in patients with inherited or acquired bleeding diatheses, including those taking anticoagulants. Keep this and all iron-containing products out of the reach of children.See full Prescribing Information for complete usage and safety data. Supplementation with DuetDHA^ec may require additional dietary intake of calcium, magnesium and vitamin E