Vitaflo Sample Request Form | Nestlé Health Science

Select your country:

Delivery To:

Hospital Name

Hospital:

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

State

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.

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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

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 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 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 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 (4 x sachets)

Glycogen Storage Disease

Glycosade unflavoured (4 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

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