Request Free Samples

Product:

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Are You a Current Customer of 180 Medical?(Required)

Yes

Type of Product(Required)

Catheter Supplies

Ostomy Supplies

Catheter Information

Product Name or Number (If Known)

Length

Male

Female

Pediatric

Fr Size if Known

What is Fr Size?

Frequency

Type of Tip

Straight

Coude

Ostomy Product Information

Which product would you like to try a sample of?

Product Name or Number (If Known)

Surgery Type

Frequency of Wafer/Pouch Change Per Day

Pouch Type

Is the Stoma Protruding?

Yes

Stoma Size

Accessories (select all that apply)

Doctor / Healthcare Provider Information

Because our products are prescription products, we will need to verify your prescription with your healthcare provider. Please provide your healthcare provider's contact information so we can reach out to them.

Doctor / Healthcare Provider Name

Healthcare Facility Name

Healthcare Provider Phone Number

Healthcare Provider Email

Upload Prescription (Optional)

Max. file size: 100 MB.

Insurance Information (Optional)

While insurance information is not required for samples, this will help us ensure that we get you set up with samples of products you'll be able to use.

Insurance Provider

Primary Policy Holder

Secondary Policy Holder

ID Number

Group Number

Customer Service Phone Number

Do you have a second applicable insurance policy?

Yes

Upload Insurance Card (Optional)

Max. file size: 100 MB.