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 US 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 (Spam requests will not be fulfilled. Who are the samples for?*Self/Loved oneMCP RecipientRecipient's Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Please enter the name of the recipient. (Requests containing false info will be ignored).Recipient's Date of Birth Date Format: MM slash DD slash YYYY Please include the member's Date of BirthRecipient or Requester's Email* Please enter a valid email address (Requests containing false info will be ignored).Email* Please enter contact email for IDT contact.Recipient Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Must be a valid US mailing address. No P.O. Boxes (Requests containing false info will be ignored).Recipient Phone*Valid US phone number. (Requests containing false info will be ignored).IDT Contact Phone*Staff from MetroCare may contact you with follow up questions.Describe Need*Please enter a brief description regarding the need for incontinence supplies. (Information regarding daytime or night time use, incontinence 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/UnderwearN/ASmall/Youth 20-34" Waist / HipMedium 34-46" Waist / HipLarge 44-58" Waist / HipXL 58-68" Waist /HipXXL 68-80" Waist /HipPlease select the requested size(s). Waist dimensions are an approximation, based on the brand/product selected.Size for Tabbed Brief/DiaperN/ASmall/Youth 20-34" Waist / HipMedium 34-46" Waist / HipLarge 44-58" Waist / HipXL 58-68" Waist /HipXXL 68-80" Waist /HipXXXL Bariatric 73-100" Waist / HipPlease select the requested size(s). Waist dimensions are an approximation, based on the brand/product selected.Bladder Control Pads/LinersThin Panty LinerModerate Bladder Control Pad 3 x 9.25"Moderate Long Bladder Control Pad 3 x 11"Maximum/Heavy Absorbency 4 x 13"Ultimate/Overnight Protection 5.5 x 15 or 16"Something Else Entirely (Please explain above)Please select the requested absorbencies (max 3, hold Ctrl & left click to select additional sizes).CAPTCHACommentsThis field is for validation purposes and should be left unchanged.