This secure sample request form is only for Healthcare Professionals only.
If you want us to send samples direct to your patient, simply complete the form below. Or if you would like multiple samples to try with your colleagues or keep in your Department please email what you would like, with your address to firstname.lastname@example.org
Please note when the form is submitted the data sent is held securely (128 bit encryption) for 24 hours whilst we process the request. It is then deleted from our server. All samples are dispatched within 24 hours of your request.
We are asking for this, because our research shows little is known about dysphagia in Surgeries. This will allow us to provide information and resources that will help them gain a better understanding..
Please let us know who this sample is for, so we can be sure to direct it to the right place when it arrives at its destination.
We do not keep their email or send marketing material.
If we send to a Nursing or Care Home, it helps to send it to your patient c/o the Clinicial Lead, Nurse Lead or Manager. Please provide those below.