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SAMPLES DETAILED QUESTIONNAIRE Needed to Process CYMED Samples

NOTE: PLEASE READ - Estimated completion time 5-10 minutes. AFTER Q#43 THERE IS STILL ONE MORE QUESTION REQUIRED. All Questions in BOLD black letters must be answered to successfully submit this Samples Ticket. If your Ticket is not closing, please review and make sure all those are answered(the last two Questions are not numbered and are required by the software). ALL INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL AND WILL NOT BE USED FOR ANY MARKETING.

Requestor Info

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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).
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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.
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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

(by submitting this form you certify you have the ostomate's permission to request these samples in his/her behalf)

Ostomate Contact Information


WE SEND IMPORTANT CUSTOMIZED AND DETAILED EMAIL PRODUCT USE INSTRUCTIONS. PLEASE ENTER IF OSTOMATE IS AT A DIFFERENT LOCATION.
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(if "Other" please complete next line)

(required for us to send you samples - some orders may require payment for shipping, depending on country)
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(if foreign # use country code first, and other format if applicable)

(if foreign # use country code first, and other format if applicable)

(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
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if "Larger" selected, please specify the approximate size in the next question.
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(the MicroSkin works best on smooth skin, but there are ways around that, but please alert us).

If yes, please explain (no CYMED products contain latex)
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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.

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
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For samples we cannot guarantee choice of color.
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Please explain what improvements you hope to find.
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Select as many as apply.

The more we understand your needs, the better we can fill them. Please be as specific as possible.

TICKET CLOSING

AN ENTRY IS REQUIRED (BY THE SOFTWARE) FOR THE NEXT TWO FIELDS, TO COMPLETE THE SUPPORT TICKET. Thank you for your understanding.
44. Would you like to make any additional comments or suggestions? (please use the large text field immediately below):
Drop files here or choose them
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Please enter "Yes" and Press the "Create Ticket" button right below - Thank you! -......................- NOTE: if the ticket still is not accepted, don't close it, but review our ticket FAQ in another browser window (right click on "KNOWLEDGEBASE" at top of this page), to check reasons why it is not closing, and try to apply the suggestions provided.
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