Request a Sample

First Name*

Last Name*

Email Address*

Phone Number*

Send samples to:

First Name

Last Name

Company (Optional)

Address Line 1*

Address Line 2 (Apt#/Suite#)

City*

State*

Zip/Postal Code*

Country*

-- Select an option -- United States (free shipping) Canada ($24.95 shipping)

Samples Needed For*

Female (Woman or Girl)

Male (Man or Boy)

Pets

Protection For*

Urinary

Bowel

Both

Absorbency Needed*

All-Night, Multiple Voids

Urge, One Heavy Void

Intermittent, Moderate

Light, Drips, Cough/Sneeze

Waist Size (Estimate Ok)*

16-28 in.

29-36 in.

37-48 in.

49-61 in.

61-75 in.

76-90 in.

91-106 in.

Product Style - Select All That Apply*

Tab-Style Briefs

Pull-On Underwear

Pads, Liners & Guards

Underpads / Bed Pads

Personal Cleansing Wipes

Booster Pads

Other Products (Specify Below)

Best Way to Reach Me

Email

Phone

How did you hear about us?

-- Select an option -- Heard on radio/podcast Search engine (Google, Yahoo, Bing, etc) Blog or publication Facebook Instagram LinkedIn Twitter Family or Friend Other Healthcare Professional

Additional details

Comments or Specific Product Requests

Sign up for exclusive promotions, product updates and the NorthShore newsletter with timely articles and helpful tips for managing incontinence.