Samsca Order Form


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:
  1. Orders can only be accepted from hospital pharmacies.
  2. 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