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Sample Request //

To receive product information or samples, please complete and submit the form below.

I'm interested in Rochester Medical products because: (Check One)

I use these types of products.
I'm a caregiver/family member of someone who uses these products.
I'm a clinician.
I'm a medical products retailer/distributor.

I'm most interested in: (Check All That Apply)

Male External Catheters
  Intermittent Catheters
  Personal Catheters
  Magic3 Catheters
Foley Catheters
Anti-Infection Foley Catheters

I'm currently purchasing/using the following product(s):

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I'm currently getting these products from:

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I'm interested in receiving samples of these Rochester Medical products:

Male External Catheters

 WideBand® Small -- 25mm
Pop-On® Medium -- 29mm
UltraFlex® Intermediate -- 32 mm
Natural® Large -- 36mm
    X-Large -- 41 mm

Personal Catheters

 Personal Catheter® Male Length Fr/Ch
Antibacterial Personal Catheter® Female Length    
Hydrophilic Personal Catheter® Pediatric Length    
Antibacterial Hydro Personal Catheter®        
I have a current prescription for intermittent catheters: Yes No
*Prescription required for samples to be sent.

Magic3 Catheters

 Magic3 Catheter® Male Length Fr/Ch
Antibacterial Magic3 Catheter® Female Length    
Hydrophilic Magic3 Catheter® Pediatric Length    
Antibacterial Hydro Magic3 Catheter®        
I have a current prescription for intermittent catheters: Yes No
*Prescription required for samples to be sent.

Foley Catheters

 Fr/Ch
I have a current prescription for Foley catheters: Yes No
*Prescription required for samples to be sent.

Anti-Infection Foley Catheters

 Fr/Ch
I have a current prescription for Foley catheters: Yes No
*Prescription required for samples to be sent.
May Rochester Medical or one of our authorized partners follow-up with you to answer any questions you may have after receiving your product samples? Yes No
Would you be interested in participating in new product surveys or receiving information about new offerings from Rochester Medical? Yes No
If you answered "yes" to either of these questions, please indicate how you prefer to be contacted:
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