STEP 1 OF 3: PATIENT INFORMATION

Please complete the fields below with information appropriate to the patient who will utilize the samples.

Sample kits contain both PKU GOLIKE packets and bars.

Metabolic dietitians can order samples here.

*Required field

Patient's First Name*

Patient's Last Name*

Email Address*

Patient's Date of Birth*

Relationship to the person for whom you are ordering samples*

Main formula used by person with PKU

How did you hear about PKU GOLIKE?

SHIPPING INFORMATION

Note: We cannot ship to PO boxes or outside of the US.

Street Address*

City*

State*

ZIP Code*

Phone Number*