Direct-to-Patient Sample Service

Your Practice or Department Details
(Please use a valid NHS email address) *

Practice or Department	*
Street Address	*
City	*
County	*
Postcode	*
First Name	*
Surname	*
Email Address	*
Contact Number	*

I declare that I am a UK Healthcare Professional *

I am a UK Healthcare Professional

Please select an AYMES Product for your patient
(Please note that Shakers are included in AYMES Shake, AYMES Shake Compact, AYMES Shake Smoothie and AYMES Shake Extra Sample Packs) *

Patient Details
(By optionally adding in the recipients contact number, they will receive delivery updates) *

Name	*
Street Address	*
City	*
County	*
Postcode	*
Phone Number	*

Delivery Instructions for Driver (please don't add order requests to this field)