Healthcare Professional Sample Request

Thank you for your interest in Owen Mumford products. The following sample request form is for Healthcare Professionals in the United States.

U.S. Healthcare Professionals, in order to assist us with best meeting your needs, please answer the questions below.

Note: If you are a Healthcare Professional outside of the United States, please contact your regional Owen Mumford office. If you are in Canada, please contact our North American office at samples@owenmumfordinc.com.

How did you hear about us?

Please check all that apply.

Website/onlineProduct literatureReceived samplesTradeshowOwen Mumford representativeDistributor representativeReferred by friend/co-workerEmailAdvertisement/MagazineAllscriptsOther

What best describes you?

Please check all that apply.

Diabetes EducatorPharmacistPhysicianPhysician’s AssistantRegistered NurseOther Healthcare Professional


Are you interested in obtaining a large sample volume?

(greater than 5 samples per item requested)?

YesNo

Which samples would you like to receive?

Please check all that apply.


4mm x 32G5mm x 31G6mm x 31G8mm x 31G12mm x 29G


4mm x 32G5mm x 31G6mm x 31G8mm x 31G12mm x 29G

Unilet LancetsAutolet Lancing DeviceUnistik 3 On-the-Go Travel Lancets (30G)

Please allow 8-10 weeks for delivery of samples. While supplies last. Only one Autolet lancing device sample allowed per request.

Where should we ship your samples?








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