Sample Request

Surgilube® samples are only available to eligible medical professionals.

Name*
First Last
Email*
Phone*
Business / Organization Name*
Business / Organization Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reason for Interest*
- Medical Professional
- Sales Representative
- Government
Primary GPO / Distributor
Referral Source*
What lubricant are you currently using?
What procedures are you using lubricant for?
Choose Product(s) to Sample*
- 5g foilpac®
- 3g foilpac®
- 31g foilpac®
- 2oz (56.7g) – flip top cap
- 4.25oz (120.49g) – flip top cap
- 5g Tube – (Metal – Elongated Tip)
- 2oz (56.7g) – screw/fez cap
- 4.25oz (120.49g) – screw/fez cap
Additional Comments