Marlen Sample Request

Sample Request

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
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

MARLEN Manufacturing & Development Co.
5150 Richmond Road • Bedford, Ohio 44146 USA
Phone: (216) 292-7060 • Fax: (216) 292-9196