Request a sample pack

Recipient name & address

Where the samples are to be sent to

Pad Style

(Select entry) All-in-one - diaper with tabs Pull up style Anaform insert - with waterproof backing (used in underwear) Anaform booster - with porous backing (used inside diaper) Male guard - universal size insert pad 575ml

Pad Size

(Select entry) Youth - waist 38-60cm 16-24" - dress size Youth Small - waist 60-80cm 25-30" - dress size 6-10 Medium - waist 70-110cm 30-42" - dress size 10-14 Large - waist 110-160cm 42-62" - dress size 14-18 Extra Large - waist 140-175cm 56-70" - dress size 18+

Pad Absorbency

(Select entry) Normal - small amount Extra - moderate amount Super - large amount Maxi - whole bladder

Bed Protection / Cleaning

(Select entry) none required bed protection / bluey - regular size - economy tissue - 400x600mm 200ml bed protection / bluey - bed size - sealed fluff - 900x1900mm with wings 2500ml bed protection / bluey - regular size - sealed fluff - 400x600mm 400ml moist cleaning cloths - large sized wet wipes 200x300mm dry wipes sample pack - rediwipe / fibrella

Is the recipient registered with NDIS?

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Referrer

Referrer name

Samples requested by

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Additional Requests

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