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Contact Information If for Samples or QC Issues, contact information is for product user experiencing this quality issue. If person filling out this form is someone else, please complete the field in this section titled "Person Completing This Form if Someone Else."
Full Name *
Email Address *
Help Topic
*
SAMPLES QUESTIONNAIRE Needed to Process CYMED Samples NOTE: PLEASE READ - Estimated completion time 5-10 minutes. Please answer as many questions as possible and all questions with a red asterisk. All information you provide us is strictly confidential!*
Requestor Info
01. Do you agree to our Samples Policy?: * If you choose no, we cannot process the request. Please read and indicate acceptance of our brief terms and policies for free samples, right-click on Knowledgebase above, then "FAQ" (Frequently Asked Questions).
02. Have you received samples from us before? * It's fine to request samples more than once if consistent with our samples policy. Letting us know you've requested samples before helps us improve your our recommendation and avoid duplication.
03. Is this request for yourself? * If yes, answer next questions that don't apply to you as "NA" If for someone else, we need to validate your email account. Please register (once)by clicking on "Sign In" (top right), then click on "Create an Account." Thank you
04. Your Name (if for someone else)
05. Relationship to ostomate (if someone else) (by submitting this form you certify you have the ostomate's permission to request these samples in his/her behalf)
Ostomate Contact Information
06. Ostomate's email WE SEND IMPORTANT CUSTOMIZED AND DETAILED EMAIL PRODUCT USE INSTRUCTIONS. PLEASE ENTER IF OSTOMATE IS AT A DIFFERENT LOCATION.
07. First Name *
08. Last Name *
09. Ostomate Age
10. Address1 *
11. Address2
12. City *
13. State *
14. Zip (or Postal Code) *
15. Country * (if "Other" please complete next line)
16. Country (if answer "Other" in #15) (required for us to send you samples - some orders may require payment for shipping, depending on country)
17. Phone1 * (if foreign # use country code first, and other format if applicable)
18. Phone2 (if foreign # use country code first, and other format if applicable)
19. Time Zone
20. Best Time Range to Call (if needed) (optional - in case we have any questions)
OSTOMY DETAILS The answers to these questions help us find the best product match. Please take the time to answer them as fully as possible. Thank you
21. Month/Year of Surgery *
22. Ostomy Type *
23. Stoma Diameter * if "Larger" selected, please specify the approximate size in the next question.
24. Specify Larger Size (if answered "Larger" to prev question)
25. Stoma Shape *
25.5 Convexity? *
25.6 Is skin around stoma smooth? (the MicroSkin works best on smooth skin, but there are ways around that, but please alert us).
25.7 Any history of sensitivity or allergy to adhesives? If yes, please explain (no CYMED products contain latex)
26. Is stoma flush/recessed or protruding? *
27. Degree of Skin Irritation if Any *
28. Any Leaking Problems? *
29. Average Days Pouch Wear Time *
30. Is visibility when putting on pouch challenging? We have an inexpensive device you strap the pouch to with a 45 degree mirror on it so you can look straight down and directly to the stoma as you position the pouch. "Applicator" see p.15 of our catalogue.
31. Other Needs
PRODUCT PREFERENCES The answers to these questions help us find the best product match. Please take the time to answer them as fully as possible. Thank you
32. Need Filter? *
33. Prefer 1 or 2 Piece ? *
34. If Colostomy, need Drainable and/or Closed?
34.1 If Colostomy, would you like info on irrigation?
35. Drain Closure Type: Clip or Velcro ? *
36. Preferred Pouch Size *
37. Preferred Pouch Color * For samples we cannot guarantee choice of color.
38. How did you learn of Cymed *
39. If answered Other to question above
40. Your main goals from trying Cymed? Please explain what improvements you hope to find.
41. Current or Past Cymed customer? *
41.1 If using Cymed products, which one(s)?
42. What product(s) are you using now? * Select as many as apply.
43. TICKET CLOSING (entry required next two fields) Please enter comments or "NA" if you have no further comments (please do not leave blank).
Drop files here or choose them
44. Have you answered all required questions? "YES" to close ticket. *

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Contact Information

SAMPLES QUESTIONNAIRE Needed to Process CYMED Samples

Requestor Info

Ostomate Contact Information

OSTOMY DETAILS

PRODUCT PREFERENCES

43. TICKET CLOSING (entry required next two fields)

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