Physician-recommended Formula:

Required Information (Fields marked with an asterisk (*) are required.)Hospital Name*:

Physician Name: Nurse Name:

Parent/Guardian (one request per household):Name*: Street (No P.O. Boxes)*:

City*: State*: Zip Code*:

Telephone*: ( ) E-Mail Address:

Are you 18 years of age or older?* ...................................................................................................................................................................................................................................... Yes No

Babies: Twins Triplets Other (specify number of babies)* Birth Date*:

Baby Names:

Were your babies admitted to the Neonatal Intensive Care Unit (NICU)?* ........................................................................................................................................................ Yes No

About Your Family:Are you interested in receiving exclusive coupon o�ers,† getting expert tips about caring for your multiples, and learning more about Similac infant formulas from www.similac.com?* ................................................................... Yes No

Would you like to receive communication about our partners?* .............................................................. Yes No

Remember: Forms sent without copies of birth certificates or hospital records of live birth, or missing required information will not be processed.

† O�ers may vary. Abbott Nutrition is not responsible for the security of any information provided.

©2019 Abbott Laboratories 162048(3)/January 2019 LITHO IN USA

Congratulations on the birth of your multiples! Abbott Nutrition, the makers of Similac® infant formulas, is pleased to o�er a complimentary product sample to parents of twins, triplets, and up. Please complete all sections and mail this form in with a copy of each baby’s birth certificate or hospital records of live birth (do not send in original birth certificates or hospital records of live birth as they will not be returned). We suggest waiting to send in your completed form until you and your babies’ doctor have settled on the best formula to meet your babies’ ongoing needs.

O�er expires when babies reach 1 year of age. Limit 1 request per family. Fill in all fields. Please print.

Questions? Call 1-800-227-5767Monday through Friday 8:30 am–5:00 pm EST

TM # (to be filled out by Abbott Nutrition)

Parent/Guardian Signature*: Date*:

Multiple Birth Program: Complimentary Product Form

X

Similac® Organic

SimilacPro-Advance™

Similac® Alimentum®

Similac® NeoSure®

Similac® for Supplementation

Similac® Soy Isomil®

Similac Pro-Sensitive™

Similac® for Spit-Up

Similac Pro-Total Comfort™

Abbott cares about my privacy.  I agree that the information I’ve provided may be used only by Abbott and its contracted third parties to mail (and email) me helpful information on my stage of pregnancy, baby feeding & nutrition, and marketing materials and promotional o�ers about related products and services.  I understand that Abbott will not sell or transfer my name or contact information to any third party for their marketing use.

For any questions or to opt out of Similac StrongMoms at any time, please contact 1-800-232-7677. A copy of the Abbott privacy statement may be obtained by visiting www.Similac.com or calling 1-800-232-7677.

ROUTINE FEEDING

SENSITIVE TUMMIES

FOOD ALLERGIES

FORSUPPLEMENTATION

Sample

(Fields marked with an asterisk (*) are required.)

Sample

(Fields marked with an asterisk (*) are required.)

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Nurse Name:

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Nurse Name: Nurse Name:

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Nurse Name:

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(one request per household)

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(one request per household):

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Street (No P.O. Boxes)*:

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E-Mail Address:

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Are you 18 years of age or older?*

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Are you 18 years of age or older?* ...............................................................................................................................

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...............................................................................................................................

Twins Sample

Twins Sample

Triplets Sample

Triplets Triplets Sample

Triplets Sample

Other (specify number of babies)* Sample

Other (specify number of babies)* Other (specify number of babies)* Sample

Other (specify number of babies)* Sample

Baby Names: Sample

Baby Names: Sample

Were your babies admitted to the Neonatal Intensive Care Unit (NICU)?*Sample

Were your babies admitted to the Neonatal Intensive Care Unit (NICU)?*

About Your Family:Sample

About Your Family:Are you interested in receiving exclusive coupon o�ers,Sam

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Are you interested in receiving exclusive coupon o�ers,getting expert tips about caring for your multiples, and learning Sam

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getting expert tips about caring for your multiples, and learning more about Similac infant formulas from www.similac.com?*

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more about Similac infant formulas from www.similac.com?*

Would you like to receive communication about our partners?*

Sample

Would you like to receive communication about our partners?*

SampleSimilac

SampleSimilac®

Sample®

Soy Isomil

SampleSoy Isomil®

Sample®

SampleSimilac

SampleSimilac

Pro-Sensitive

SamplePro-Sensitive™

Sample™

SampleSimilac

SampleSimilac®

Sample®

for Spit-Up

Samplefor Spit-Up

SampleSimilac

SampleSimilac

Pro-Total Comfort™

SamplePro-Total Comfort™

Sample

Sample

Sample

Sample

SampleSENSITIVE

SampleSENSITIVE

TUMMIES

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FOOD

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ALLERGIES

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