Abstract: A combination preselected medication sample prescription form, sample payment check, and medication sample regulating device includes a support panel having an obverse and a reverse surface and defines first, second and third portions thereof. An area for receiving written, printed or typed patient identification information is viewably applied over the obverse surface of the first portion which also includes a medication prescription form, the entire first portion being detachable from the adjacent second portion along a transverse tear line of weakness. The second portion, positioned on the support panel centrally between the first and third portions, includes manufacturer's product information printed on both the obverse and the reverse surfaces thereof. The third portion includes a preprinted payment check for a sample quantity or as a partial payment for a larger quantity of preselected medication.

Abstract: A combination medication sample, in a reusable container and medication prescription device includes a flat support panel having an obverse or front facing surface which defines a first and second portion thereof. A removable, reusable medication container holding a small sample quantity of medication in pill, tablet or capsule form is viewably attached to the first portion and a removable medication prescription form is attached to the second portion of the front surface of the support panel. This combination permits the physician to simultaneously distribute a starter quantity of medication and to write a prescription for a larger quantity of medication. A cover panel for protecting the prescription form, a pocket for holding printed material relating to the medication, and ample space for printed promotional indicia on behalf of the prescription manufacturer are also provided.