Samsca Order Form

The information in this section is for Healthcare Professionals only

Click here for the Samsca Order Form

The information provided on the following pages is intended for Healthcare Professionals only. By continuing you are confirming that you are a Healthcare Professional.

The information in this section is for Healthcare Professionals only



ORDER HELPLINE: +44 (0)203 7475000

You can order Samsca® (tolvaptan) using the form below.

For assistance in completing the form please refer to the Frequently Asked Questions (FAQs).

Please note:
  • Orders can only be accepted from hospital pharmacies.
  • There may be specific procedural requirements for the purchase of medicinal products that have a marketing authorisation, but are not currently available in your country.
  • It is your responsibility to ensure that you have complied with any such requirements.

Product required

*Indicates mandatory fields

Please select which pack combination you would like to order:

Product Cost ()

Cost of Samsca
Total Invoice Amount
(including packaging and shipping, excluding VAT)

Hospital Details (Delivery Address)

Requesting Hospital Pharmacist

Requesting Hospital Physician

Invoicing Details

Date of preparation: September 2017

Reference OPEL/0917/GEN/1111