Keneric Healthcare Sample Request Form
Please provide the following information and a Keneric Healthcare associate will contact you about your no cost product evaluation kit!

PLEASE NOTE: RTD™Wound Dressings are prescription only - Samples may only be requested by licensed clinicians.
IF you are a patient and would like information sent to your healthcare provider,
please contact us directly via email: sales@kenerichc.com

Email address
Which product would you like samples of?
Credentials (Dr., RN, WOCN, etc)
Your answer
Please submit your name
Your answer
Phone
Your answer
Facility/Clinic or Company
Your answer
Street Address
(Please enter the facility address where the evaluation will take place)
Your answer
City
Your answer
State
Your answer
ZIP
Your answer
Purpose of your Sample Request?
Your answer
Who is your facility's preferred medical supply distributor?
Your answer
A copy of your responses will be emailed to the address you provided.

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