Request a Sample

If you're an eligible healthcare professional you can request AKYNZEO® oral samples for your patients.

Please fill in your information in the form below and one of our representatives will reach out with the Sample Request Form to process your request.

*AKYNZEO is distributed and marketed by Helsinn Therapeutics (U.S.), Inc. ("Helsinn"). By submitting this form, I certify that I am either a licensed practitioner currently authorized under applicable law to request, receive, and dispense these drug samples for the legitimate medical needs of my patients or an office staff member of such practitioner and give permission to Helsinn to contact me regarding the AKYNZEO® Sample Program. Helsinn reserves the right to decline requests for samples from practitioners whose medical practice or patient population is deemed inconsistent with the approved product indication(s).

**Field is required.

Please refer to Helsinn's Privacy Statement at