Sample Request Form

Thank you for your interest in Genairex® products. To request a free product sample, please submit the information below. Please be as specific as possible, so that we can provide samples that are tailored to your needs. If you would like personal assistance please call our clinical assistance @ 1-877-726-4400.

* Indicates required information
   
Specific products you would like to sample:
   
*First Name
*Last Name
*Street Address
*City
*State / Province
*Zip Code
*Country
*Phone Number
*E-Mail Address
   
Supplier: Where do you get your ostomy supplies?
   
Insurance is:
Medicare
Medicaid
Private Carrier
*Type of ostomy
Colostomy
Ileostomy
Urostomy
*Stoma Size
*Stoma is
Protruding
Retracted
Round
Flat
Irregular Shape
   
What brand of ostomy product do you currently use?
ConvaTec
Hollister
Other
Product Numbers
*What style of wafer are you using?
Precut
Cut-To-Fit
Flat
Convex
What type of ostomy accessories are you using? (Select all that apply.)
Paste
Barrier Rings
Pouch Deodorants
Other
   
Please explain any problems you are experiencing with your current appliance:
   
Would you like information on new products?
   
 

Privacy Statement: Your privacy is important to Genairex, Inc. We will not sell or rent your personal information to third parties. The information you provide will be used solely by us to contact you if needed additional information about your request. Information will be shared with a service provider only at your request.