Request a Sample

STEP 1 OF 4: PATIENT INFORMATION

Please complete the fields below with information for the person you are ordering samples for.

Sample kits contain both PKU GOLIKE packets and bars.

Metabolic dietitians can order samples here.

*required field

Patient First Name*

Patient Last Name*

Your Email Address*

Date of Birth (of the person the sample is for)*

What is your relationship with the person you are ordering the sample for?*

What is the current main formula of the person with PKU?

How did you hear about PKU GOLIKE?