Zipper Kit Request Form
Fill in the form to request to test out our product. You must fill in the entire form in order to receive a test kit.
Would you be willing to provide your feedback on our product? If so, after receiving it, you will be emailed a link to login and provide answers to a brief survey.
Do any of the following situations apply to you or someone you know?
Type 1 Diabetes (body does NOT make insulin at all)
Type 2 Diabetes (body makes insulin but resists using it)
Currently undergoing Cancer treatment(s)
Use of a G-tube (feeding tube)
None of the above
If any of the above situations apply, are you requesting this kit to help in making administering medications easier?
If I am selected to receive a free limited Zipper Kit®, I agree to all of the following: 1. I will provide to StraightShot Apparel only feed back on the product. 2. Because this product has proprietary and protected elements, I agree to sign a confidentiality/non-disclosure agreement. 3. I understand I may be invited to participate in a product feedback meeting, within reason, I am willing to attend such a meeting.
To send me my free limited Zipper Kit®, please send it to the address below (include first name, last name, address, city, state, zip code):
Thank you for requesting to test our product.
All rights reserved to StraightShot Apparel and ZIpper Kit. The information you provide will not be given out to anyone, your privacy is protected with us. Your email, name, and address will only be used for the purpose of sharing/receiving information related to our products. If you have any questions please email us at
A copy of your responses will be emailed to the address you provided.
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