Medical Information Request Form

First Name*

Last Name*

Title*

Facility Name*

Facility Address*

Facility City*

Facility State/Province*AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNewfoundland and LabradorNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthwest TerritoriesNova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon

Facility Country*

Work Phone*

Mobile Phone

Email Address*

Which product are you requesting information for? Please explain your request.

2% CHG Cloths

Oral Care

Comfort Bath

Comfort Shield

Prevalon Line (Heel Protector, TAP, SPS, AirTAP, Liftaem)

Other products

Yes, I acknowledge I am personally requesting this information, unsolicited, through the Clinical Sciences/Regulatory Affairs Department and expect to receive unbiased, truthful and non-misleading information specific to this request. I understand I will receive this information from a Registered Nurse.*

We’d like to take this opportunity to remind you that Sage Products respects and recognizes your privacy. The information that you provided to us will be used for the purposes of processing your Medical Information request and stored in a database which is the property of Sage Products. For information about Sage Products’ privacy policy visit our website at https://sageproducts.ca/privacy-policy/.