Ultramax Gemini Two-Piece ostomy System
UltraMax One-Piece Disposable Ostomy System

Thank you for requesting a sample of a Marlen Ostomy Appliance. This online form is limited to one sample per request. For multiple samples, simply fill out and submit the form multiple times or if you prefer to request your sample(s) by phone, please call 216.292.7060 between 8:00 AM and 4:00 PM EST (Monday – Friday).

*I am a: Nurse      Patient       *required information
Please provide the following information:
*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip code :
*Phone:
*E-mail:

If you are a WOCN nurse, please provide your hospital affiliation and your reason for requesting a Marlen pouch.
Hospital:
Comments:
*Surgery Type: Colostomy      Urostomy      Ileostomy
Stoma Size:

*Do you prefer a pre-cut flange or a cut-to-fit flange?
Pre-Cut Cut-to-Fit

*Please specify which type pouch that you would like to sample (select only one):
 Marlen UltraMax Gemini 2-Piece Ostomy System
Please Choose Flange Convexity: Shallow     Flat
UltraMax Gemini Drainable with Kwick-Klose™ closure system:
Opaque (with Kwick-View feature) WITH filter
Opaque (with Kwick-View feature) WITHOUT filter
Transparent WITH filter
Transparent WITHOUT filter
UltraMax Gemini Closed End
Opaque (with Kwick-View feature)
Transparent
UltraMax Gemini Urostomy
Opaque (with Kwick-View feature)
Transparent
 Marlen UltraMax 1-Piece Ostomy System
UltraMax Drainable with Kwick-Klose Fastener & AquaTack Hydrocolloid barrier
Choose Convexity:
Shallow     Flat
UltraMax Closed End with AquaTack Hydrocolloid Barier
Choose Convexity:
Shallow     Flat
UltraMax Urostomy with AquaTack Hydrocolloid Barrier
Choose Convexity:
Shallow     Flat
 Marlen UltraLite
UltraLite Drainable (must make a selection under each option below)
Choose Convexity:
Deep     Shallow    Flat
Choose Barrier Style:
With SkinShield™ Adhesive Skin Barrier
With AquaTack™ Hydrocolloid Barrier
Choose Fastener:
With Kwick-Klose Fastener
Without Kwick-Klose Fastener
UltraLite Urostomy (must make a selection under each option below)
Choose Convexity:
Deep     Shallow    Flat
Choose Barrier Style:
With SkinShield™ Adhesive Skin Barrier
With AquaTack™ Hydrocolloid Barrier

UltraExtra Drainable FOR STOMA OPENINGS UP TO 3”
        (Call for stoma size options and choice of Flat—U-cut, Oval Convex or Round Convex         in either transparent or opaque material)

UltraPlus Drainable FOR STOMA OPENINGS UP TO 3-1/2”
        (Call for stoma size options and choice of Flat—U-cut, Oval Convex or Round Convex         in either transparent or opaque material)
 UltraSeal

UltraSeal Flexible Barrier Ring (select size below)

        Regular Size (2” outside diameter – 5/8” starter hole
        Large Size (3-3/4” outside diameter – 7/8” starter hole

Security Code:
Please enter the words you see in the box, in order and separated by a space.