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Samples & Savings

Offer your patients something more. Our ACT® Professional Support program is designed to help you and your patients get the most of ACT® products and resources.

Sign up and receive:

FREE patient coupons
Special sample offers

Downloadable patient materials
Professional literature, and more!

All fields required unless marked optional.

First Name

Last Name

Email Address

Other Title

Practice Name

State License Number (Optional)

Address Line 1

Address Line 2 (Optional)

City

State

ZIP Code (xxxxx or xxxxx-xxxx)

Phone (xxx-xxx-xxxx)

Promo-Code (Optional)

Please Select One

The address information provided is a practice/office/business address.The practice address information provided is located at a residential address.The address information provided is a residential address. Note: Fulfillment of any future sample offers cannot be shipped to residential addresses or P.O. Boxes. Practice address is preferred.