Sample/Sales Representative Inquiry

The Sample /Sales Representative inquiry form is a resource for Healthcare Professionals. Please complete the form below and submit to Eli Lilly and Company to inquire about samples and/or a sales representative.

Samples inquiry may only be requested by Prescribing Healthcare Professionals.

Fields with (*) are mandatory

Type of HCP *

Product *

Samples are not available for Basaglar, Emgality, Humalog, Kisunla, Mounjaro, Trulicity or Zepbound.

HCP Specialty *

Prescriber contact info:

Title (e.g. Dr., Mr., Mrs.)

Prescriber NPI (10-digit) *

Look up your NPI number

First Name *

Last Name *

Phone *

Email *

Office contact info:

First and Last Name *

Street Address *

State *

City *

Zip Code *

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