FREE SAMPLE - MetroCare

Request a FREE Incontinence Garment Sample

Please complete this form to receive a free sample of select incontinence products. A sample will be provided and shipped to a physical Wisconsin mailing address (excluding P.O. Boxes) at no cost to you. *Certain restrictions and limitations apply. You agree to be contacted with follow up questions pertaining the samples dispensed (invalid requests will not be fulfilled).

Who are the samples for?*
- Self/Loved One
- MCP/Family Care Recipient
Recipient's Name*
Prefix First Last Suffix
Please enter the name of the recipient. (Requests containing false info are considered invalid).
Untitled*
- Female
- Male
- Choose not to identify as either
Please provide the gender of the MCP recipient. This information is not used to identify the member, rather to better provide samples which may fit more comfortably.
Recipient's Date of Birth
Date Format: MM slash DD slash YYYY

Please include the member's Date of Birth
Recipient or Requester's Email*

Please enter a valid email address (Requests containing false info are considered invalid).
IDT Contact Email*

Please enter email for IDT contact.
IDT Contact Phone*
MetroCare associates may reach out with follow up questions.
Recipient Address*
Street Address Address Line 2 City ZIP Code

Must be a valid Wisconsin mailing address. No P.O. Boxes (Requests containing false info are considered invalid).
Recipient Phone*
Valid US phone number. (Requests containing false info are considered invalid).
Describe Need*
Please enter a brief description regarding the need for incontinence supplies. (Information regarding daytime or night time use, incontinence occurrence frequency, and absorbency level is helpful in determining what samples to send). Height and weight is also helpful in determining the correct incontinence care.
Type of Samples Requested*
- Pull Up/Underwear
- Tabbed Brief/Diaper
- Liner/Bladder Control Pad
Please select the type of samples requested *(Limit Two).
Size for Pullup/Underwear
Please select the requested size(s). Waist dimensions are an approximation, based on the brand/product selected.
Size for Tabbed Brief/Diaper
Please select the requested size(s). Waist dimensions are an approximation, based on the brand/product selected.
Bladder Control Pads/Liners
Please select the requested absorbencies (max 3, hold Ctrl & left click to select additional sizes).
Does recipient reside in Wisconsin*
Samples will only be dispensed to valid Wisconsin addresses. If a request is to non-Wisconsin address, the request will be discarded. Please cancel this request if the recipient resides outside of Wisconsin.
Site Security Challenge
Click the box above confirming request validity.
Comments
This field is for validation purposes and should be left unchanged.