Request Samples

At Strive Medical, we understand at times finding the right supplies may be challenging.

Please complete the form below to request complimentary samples. A prescription from your physician is required.

"*" indicates required fields

I would like to request samples of:

Urology (catheters, urinary drain bags, etc.)

Prescription Required

Incontinence (briefs, underpads, etc.)

Additional information (e.g. French, Size, Length, Product Name, etc)

Are you new to using these supplies?

Yes

First Name*

Last Name*

Date of Birth*

Best Phone Number*

Check Box For :

Cell

Work

Home

Email*

Have a prescription? Email it to orders@strivemedical.com.

Yes

Primary Insurance Name

Any other information you want to share?

Verify Your Identity

Name

This field is for validation purposes and should be left unchanged.

* We will contact you using the information you provide in the form above. Thank you.