2-Pack Sample Request Form

2-Pack Sample Request Form:
Request a 2-pack sample of the following
products. Limit 2 items per customer.
Sample Recipient: _____________________________________________________________
Street Address: ________________________________________________________________
City: ____________________________________________ State: _______ Zip: ___________
Capacity
Packaging
Small 22”-36” w/h; 80-125 lbs.
Medium 34”-48” w/h; 120-175 lbs. Large 44”-54” w/h; 170-210 lbs. X-Large 48”-66” w/h; 210+ lbs.
14.5 fluid oz.
19.0 fluid oz.
19.0 fluid oz.
19.0 fluid oz.
Pk22, Cs88 Pk20, Cs80
Pk18, Cs72
Pk14, Cs56
Small 24-32” w/h
Medium 32-44” w/h
Large 45-58” w/h
X-Large 56-64” w/h
11.8 fluid oz.
15.8 fluid oz.
19.3 fluid oz.
23.0 fluid oz.
Pk10, Cs100 Pk12, Cs96
Pk12, Cs72
Pk 8, Cs64
Underpad - Large 23” x 36”
8.1 fluid oz.
Pk25, Cs150
o 2760 Booster Pad 12” x 4.25”
6.7 fluid oz.
Pk25, Cs200
OverNight X-Small 17”-28” w/h; 65-85 lbs.
OverNight Small 22”-36” w/h; 80-125 lbs.
OverNight Medium 34”-48” w/h; 120-175 lbs. OverNight Large 44”-54” w/h; 170-210 lbs. OverNight X-Large 48”-66” w/h; 210+ lbs.
20.3 fluid oz.
20.3 fluid oz.
34.0 fluid oz.
34.0 fluid oz.
34.0 fluid oz.
Pk22, Cs88 Pk20, Cs80 Pk18, Cs72
Pk16, Cs64
Pk14, Cs56
ATN (All-Through-the-Night) X-Small 18-26” w/h
ATN (All-Through-the-Night) Small
24-32” w/h
ATN (All-Through-the-Night) Medium 32-44”w/h
ATN (All-Through-the-Night) Large 45-58” w/h
ATN (All-Through-the-Night) X-Large 56-64” w/h
XL+ Bariatric 64-90” w/h
18.5 fluid oz.
22.2 fluid oz.
27.5 fluid oz.
33.0 fluid oz.
34.0 fluid oz.
34.0 fluid oz.
Pk10, Cs100 Pk10, Cs100 Pk12, Cs96
Pk12, Cs96
Pk12, Cs72
Pk8, Cs32
o
o
o
o
Item
Light to Moderate Protection
Incontinence Products
Disposable Absorbent Underwear
2604
2605 2606 2607 Disposable Briefs
o
o
o
o
2620 2624 2634 2635 Underpad
o 2675
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Description Size
Booster Pad
Heavy to Maximum Protection
Disposable Underwear
2113 2114 2115 2116 2117 Disposable Briefs
2183 2184 2185 2186 2187 2190 SlimLine® Breathable Brief
2305 2306 2307 Breathable Medium
Breathable Large
Breathable X-Large
32-44” w/h
45-58” w/h
56-64” w/h
20.4 fluid oz.
21.4 fluid oz.
23.7 fluid oz.
Pk12, Cs96
Pk12, Cs96
Pk12, Cs72
Peach Sheet Underpad
21.5” x 32.5”
34.0 fluid oz.
Pk12, Cs96
TopLiner Booster Pad TopLiner Booster Contour Pad TopLiner Booster Super-Plus Contour 14” x 4”
21.5” x 14”
32” x 14”
10.9 fluid oz.
13.6 fluid oz.
27.5 fluid oz.
Pk25, Cs200
Pk12, Cs120
Pk12, Cs96
Underpads
2074
Booster Pads
2070 3096 3097 Help Desk: Fax back completed form to the number below. For help in the assessment process or to order product, contact:
Incontinence Assessment Guide
A consumer service of Tranquility® Incontinence Products
Conditions to consider:
The number of boxes checked below helps determine which
product best fits your needs.
Select Disposable
Absorbent Underwear
Urine Odor
Heavy Voids
1-3
Select
Disposable Briefs
Problems with Leakage
Light to
Moderate
Limitation in Mobility
Fragile Skin
Tranquility SlimLine
Breathable Briefs
History of UTIs / Skin Breakdown
Dementia
Tranquility
OverNight Disposable
Absorbent Underwear
Medicated
(on meds that may complicate toileting)
4-7
Bowel Incontinence
(add a contour liner)
Heavy to
Maximum
Tranquility ATN
Disposable Briefs
Uninterrupted Sleep is Necessary
(fewer checks and changes)
Combative Behavior
Concerned about Caregiver Fatigue
Currently Using:
Product Style _________________
Size _________________________
Brand Name __________________
Tranquility
TopLiner Booster Pads*
Tranquility TopLiner
Contour Booster Pads*
8 - 12
Extra
Absorbency
for Special
Needs
Select
Underpads
Tranquility
Peach Sheets
*Brief + TopLiner Booster Pad = Increased Absorbency.
Disposable Underwear + TopLiner Booster Pad = Increased Absorbency.
Product Samples: See back of form for details.
© 2009 Principle Business Enterprises, Inc.
12TRQ-583-SL09