PolyMem, the Polymeric Membrane Dressing-Sample Request
Please fill in all the necessary information please note * for REQUIRED information
Agency/Facility (If Applicable)
Where are you using product?
Long Term Care
Sample Request Type:
Note: For non patient specific sample request we will send out a variety of sizes and styles for review unless otherwise noted below
Not Patient Specific
Diabetic Foot Ulcer
Post Surgical Wound
Burn ( 2nd degree, radiation therapy)
Hand Therapy ( Finger /Toe Cots)
Note: PolyMem may stimulate increased exudate as it leads to healing initially.
5045 PolyMem Max 4.5"x4.5" For High to Moderate ExudateI
1045 PolyMem Max Silver 4" x 4" For High to Moderate ExudateI
1044 PolyMem Silver 4.25" x 4.25"
1814 PolyMem Silver Wic Rope
1333 PolyMem Silver Wic ( For depth greater than .5cm)
5733 PolyMem Wic (For depth greater than .5 cm)
4401 Finger Cot (Small) #1 Ring Size
4402 Finger/Toe Cot (Medium) #2 Ring Size
4403 Finger/Toe (Large)Cot #3
Not Patient Specific- Variety Pack
Approximate Age of the wound
> 1 year
Provide us with some information - wound size, history, require silver etc.
How did you hear about Polymem?
Healthcare Professional Recommendation
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