Welland Medical America

Patient Sample Request Form

Name:______________________________________________________________________________

Address:____________________________________________________________________________

____________________________________________________________________________________

City:________________________________ State:__________ Zip Code:______________________

Day Phone:________________________________Night Phone:_______________________________

E-mail:______________________________________________________________________________

Date of most recent ostomy surgery: _____/ _____/ _____

Surgery Type: please check box ð Colostomy ð Ileostomy ð Urostomy

Stoma Size:_______________ inches

WOC/ET Nurse’s Name:______________________________________

Facility:____________________________________________________

Flushable Pouch: ð 6 pouch sample pack (cut-to-fit) ð Fistula or Pediatric Pouch (cut-to-fit)

Curvex:

Type:

ð Closed End ð Drainable ð Drainable with integrated clip ð Urostomy

Size (cut-to-fit):

ð Small Plateau (½” - 1”) ð Medium Plateau (½” - 1 ¼”) ð Large Plateau (½” – 1 ¼”)

Color:

ð Transparent ð Beige

Accessories: check all that apply ð Literature ð Fistula / Pediatric Pouch

ð Hydroframe ð WBF No Sting Wipes ð Appeel No Sting Wipes ð Osto Seal

Nurse/Doctor/Professional

Signature:____________________________________________________________________

PLEASE NOTE :

Flushable Pouch Samples are not given directly to Patients

as they require fitting by a Healthcare Professional

Please complete this form and fax it to us at 1-450 424 1865

Or mail to: Montreal Ostomy Center, 197 Joseph Carrier, Vaudreuil, Quebec, Canada J7V 8P3