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Request Samples Form

Request Samples

To request product samples, please indicate the product number or product category you are interested in below. Have questions? Call 800-321-2313 to speak directly with a Puritan representative (207-876-3311 if outside the United States or Canada). We do not supply samples for personal use. If you are a non-profit organization in need of medical supplies, you may contact us here.

First Name*

Last Name*

Company Name*

Product # or Product Category

Intended Use*

Work Email*

Job Title

Street Address*

Street Address 2

City*

State/Region/Province*

Country*

Postal Code*

Industry*

What distributor or vendor do you currently use for swabs and supplies?*

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