PolyMem, the Polymeric Membrane Dressing-Sample Request
Please fill in all the necessary information please note * for REQUIRED information
Name *
Your answer
Agency/Facility (If Applicable)
Your answer
Address *
Your answer
City *
Your answer
Province *
Postal Code *
Your answer
Telephone: *
Your answer
Email: *
Your answer
Are you? *
Where are you using product? *
Required
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
Wound Type *
Product Request
Note: PolyMem may stimulate increased exudate as it leads to healing initially.
Approximate Age of the wound *
Provide us with some information - wound size, history, require silver etc. *
Your answer
How did you hear about Polymem?
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