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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).
  • Please enter the name of the recipient. (Requests containing false info are considered invalid).
    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.
  • Date Format: MM slash DD slash YYYY
    Please include the member's Date of Birth
  • Please enter a valid email address (Requests containing false info are considered invalid).
  • Please enter email for IDT contact.
  • MetroCare associates may reach out with follow up questions.
  • Must be a valid Wisconsin mailing address. No P.O. Boxes (Requests containing false info are considered invalid).
  • Valid US phone number. (Requests containing false info are considered invalid).
  • 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.
    Please select the type of samples requested *(Limit Two).
  • Please select the requested size(s). Waist dimensions are an approximation, based on the brand/product selected.
  • Please select the requested size(s). Waist dimensions are an approximation, based on the brand/product selected.
  • Please select the requested absorbencies (max 3, hold Ctrl & left click to select additional sizes).
  • 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.
  • Click the box above confirming request validity.
  • This field is for validation purposes and should be left unchanged.
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    Mequon, WI 53092
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