Patient Brochure Order Form

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The Abbott Ambassador Program supports Healthcare Professionals by providing important nutrition information and patient support for the Ensure^® and Glucerna^® brands. As part of the Ambassador Program, you’ll be eligible to receive patient resources, including samples and coupons, shipped directly to your office.

If you’re a credentialed Healthcare Professional, complete the form below with the details for your primary practice location. If you have previously signed up for the Abbott Ambassador Program and would like to update your account, please call Abbott Consumer Relations at 1-877-457-1869.

Our goal at Abbott is to help Healthcare Professionals like you put their patients on the path to better nutrition.

Join today!

*Indicates Required Fields:

Healthcare Professional Information

First Name*

Last Name*

Healthcare Professional Specialty*

10-digit NPI number*

CDR Registration Number

Email Address*

Patient Count (Per Month)*

Facility shipping Information

Practice Name*

Please indicate type of care setting*

Address*

Please Note: We are only able to ship to Business Locations.

Suite/Unit*

City*

State*

Zip*

Phone Number*

Request Nutrition and Patient Materials

What type of materials would you like to receive?* (check all that apply)

Product Samples

Coupons

Patient Resources

Educational Opportunities

Are you requesting materials for Ensure and/or Glucerna?*

Ensure

Glucerna

Requested number of Ensure product samples per month

Requested number of Glucerna product samples per month

I understand that the information I’ve provided will be used by Abbott and its contracted third parties to provide me with helpful information about Glucerna and Ensure and to send me marketing materials and promotional offers via email about Abbott’s products and services. Abbott will not sell or transfer my personal information to any other party for their marketing activities. To be removed from the Glucerna and Ensure mailing list, unsubscribe or contact 1 800 227 5767.

The Abbott Ambassador Program is intended only for introducing products to patients and may not be sold, transferred, or otherwise offered to third parties. The Program is offered on an “as available” basis and does not guarantee you will receive the product sample you request. Abbott may discontinue or modify the sampling program at any time at our sole discretion.

By submitting the information above, you agree that it will be governed by our site’s Privacy Policy. Providing your personal information through this form will be treated the same as if you provided a physical signature.

Welcome to the Abbott Ambassador Program!