Request a Sample

Patient Profile Information

*First Name:

*Last Name:

*Email:

*Relationship to the Patient

*How did you hear about the sample program:

Select the formula samples you’d like to receive:

KetoCal® 4:1 LQ

Chocolate

Unflavored

Vanilla

		KetoCal® 4:1 Powder

		KetoCal® 3:1

Shipping Information

Note: We cannot ship to P.O. Box addresses

*Street Address:
Address2:
*City:
Country:
*State:
*Zip Code:
*Phone:	(Format: xxx-xxx-xxxx)

Healthcare Professional Information

KetoCal® products are categorized for use under medical supervision. To comply with the highest standards recognized by federal law, we are required to obtain your clinician’s approval before shipping.

*Ketogenic Clinician Full Name:

*In which state is your clinic?:

*Dietitian Email Address

*Confirm Email Address

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Terms Acceptance
By participating, you acknowledge that your personal information will be processed by Danone North America Public Benefit Corporation, its affiliates, and subsidiaries (collectively "DNA PBC") for purposes of fulfilling your orders, and for other purposes in accordance with Danone?s Privacy Policy. Your information may be shared with trusted partners to fulfill these purposes.

Request a Sample

Patient Profile Information

Shipping Information

Healthcare Professional Information

Terms Acceptance