Go to Top

Request Samples

Samples Request Form

Please fill out this form entirely. Once we have received your request you will receive a confirmation e-mail and an attachment of your submitted request.
  • Facility Information

  • User Information

    If you are not a current customer, a sales representative will be in contact with you to set up your information in our system so we can send out samples to you without delay.
  • Samples Information

  • Drape Manufacturer:Product Number:Type of Drape:Size Dimensions:Sterile (Yes / No):Monthly Usage: 
    Add a row
    If you do not have some of the information required above please fill in "N/A". Please note that the more complete the form, the better cross-referencing we can provide you with.

    If you need to provide us with additional information or need special requirements please fill out the separate area below with any other details.
  • This field is for validation purposes and should be left unchanged.