AinsCorp Order Samples

ORDER SAMPLES

* Indicates required field

Title *

E.g. Miss, Mrs, Mr

Name *

First

Last

E.g. John Smith

Phone Number *

E.g. 03 9000 0000

Contactable Hours *

E.g. 9am-5pm Mon-Thurs

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What Brand of Product Do You Currently Use? *

What Kind of Stoma Do You Have? *

Colostomy Ileostomy Urostomy

What Type of Pouch Do You Use? *

Closed Drainable Urostomy

Is it a 1-piece or 2-piece? *

1-Piece 2-Piece

Convex or Flat? *

Convex Flat

Are You a: *

How Long Have You Had a Stoma? *

What is Your Stoma Size? *

Are You Experiencing Any of the Following? *

Leakage Sore Skin Adhesion Other (Please answer in the Comment section below)

Comment *

What Salt's Products Would You Like to Sample (Please include product name & code if known) *

Reasons for Sampling Salts Products *

Can we check in with you? *

I consent to a follow-up call with a Stomal Therapy Nurse from Ainscorp's eClinic in relation to the samples ordered

Send

AinsCorp Pty Ltd
Australia
PO Box 572 Niddrie Victoria 3042 Australia
Tel: +03 9336 3000 | Fax: +03 9336 1644
Toll Free: 1300 784 737
Email: [email protected]

New Zealand
PO Box 16150 Sandringham Auckland 1351
Tel: +64 21 909 321
Toll Free: 0800 100 146
Email: [email protected]