You must have JavaScript enabled to use this form. Select your country: - Select -AustraliaNew Zealand Delivery To: - Select -Hospital Patient Hospital Name Hospital: Hospital: - Select -Starship Child Health Adult and Paediatric National Metabolic ServiceChristchurch HospitalOther Hospital Name Other Hospital Name Hospital Address: Building 30, 2 Park Road, Grafton Postcode: 1142 Region: Auckland Hospital Address: 2 Raccarton Rd, Christchurch Postcode: 8140 Region: Waitaha Canterbury Dietitian Name Dietitian Phone No. Dietitian Email Patient Name Contact Name (If different from patient name) Delivery Address Hospital Address Town/City Town/City State - Select -VICNSWQLDSAWATASNTACT Post Code Post Code Loading Dock Information All hospital deliveries will be via loading dock. Contact Number Specific Delivery Instructions Hospital Name Dietitian Name Dietitian Email Address Region Country: New Zealand Vitaflo will supply the samples directly to the patient or (where the patient is under 13) the patient’s parent or guardian. By providing the patients’ name, address, date of birth and other information, and by ticking the box to acknowledge that you have read this advice, you confirm that you have obtained the patient’s consent (or the permission of the patient’s parent/guardian where relevant) to share the patient’s personal data with Vitaflo for the purpose of supplying product sample(s) to the patient. Patient consent confirmation .separator-line { width:100%; border-top:solid 2px #15145F; } Select Your Samples If you require more than one of a product sample, please specify in the additional requirements box at the bottom of the form Select your samples PKU sphere20 (10 sachets) Please note: Minimum order of 10 sample packs. Please select desired quantity below. Quantity - Select -10152025 Phenylketonuria (PKU): PKU Start (1 x tin) PKU Squeezie (7 x pouches) PKU explore5 (10 x sachets) PKU explore10 (12 x sachets) PKU express15 (10 x sachets) PKU express20 (10 x sachets) Flavourpac assorted flavours (8 x sachets) PKU cooler10 (10 x pouches) PKU cooler15 (10 x pouches) PKU cooler20 (10 x pouches) PKU air20 (10 x pouches) PKU sphere15 (9 x sachets) PKU sphere20 (10 x sachets) PKU sphere20 liquid (6 x bottles) Phenylketonuria (PKU): PKU Start (1 x tin) PKU explore5 (10 x sachets) PKU explore10 (12 x sachets) PKU express20 (10 x sachets) PKU sphere20 (10 x sachets) Maple Syrup Urine Disease (MSUD): MSUD explore5 (30 x sachets) MSUD express15 (30 x sachets) Flavourpac assorted flavours (8 x sachets) MSUD cooler15 (6 x pouches) MSUD cooler20 (6 x pouches) Maple Syrup Urine Disease (MSUD): MSUD explore5 (30 x sachets) MSUD express15 (30 x sachets) Homocystinuria (HCU): HCU explore5 (30 x sachets) HCU express15 (30 x sachets) Flavourpac assorted flavours (8 x sachets) HCU cooler20 (6 x pouches) Homocystinuria (HCU): HCU explore5 (30 x sachets) HCU express15 (30 x sachets) Tyrosinaemia (TYR) TYR explore5 (30 x sachets) TYR cooler20 (6 x pouches) TYR sphere20 (6 x sachets) Tyrosinaemia (TYR) TYR explore5 (30 x sachets) TYR sphere20 (6 x sachets) Glutaric Aciduria Type 1 (GA1) / Pyridoxine Dependent Epilepsy (PDE): GA gel (30 x sachets) Flavourpac assorted flavours (8 x sachets) Glutaric Aciduria Type 1 (GA1) / Pyridoxine Dependent Epilepsy (PDE): GA explore5 (30 x sachets) Methylmalonic acidaemia (MMA) and Propionic acidaemia (PA): MMA/PA express15 (30 x sachets) Flavourpac assorted flavours (8 x sachets) Methylmalonic acidaemia (MMA) and Propionic acidaemia (PA): MMA/PA explore5 (30 x sachets) MMA/PA express15 (30 x sachets) Urea Cycle Disorders (UCD) EAA supplement (30 x sachets) Support Range Flavourpac assorted flavours (8 x sachets) Glycogen Storage Disease Glycosade unflavoured (3 x sachets) Glycogen Storage Disease Glycosade unflavoured (3 x sachets) Fat Metabolism / Ketogenic Lipistart (1 x tin) K.Yo Chocolate (4 x tubs) K.Yo Vanilla (4 x tubs) Fruitivits (10 x sachets) Renal Renastart (1 x tin) Renastep (24 x bottles) Please request any additional products, literature, and accessories, in the box below Please request any additional products, literature, and accessories, in the box below I agree to Vitaflo processing my personal data as set out in the Privacy Policy. Read our Privacy Policy here. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. **To avoid submitting multiple orders, please only press the SUBMIT button once. A confirmation email will be sent to confirm your request. (If you cannot see this e-mail please check your junk folder)** SUBMIT Leave this field blank