Secure Sample Request

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 samples@slodrinks.com

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.

Name

Email(Required)

Phone number

Please can you give us a contact number in case we need to contact you - Note we will only use this number for this purpose.

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..

Surgery Name

Doctor

Recipients name

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.

Recipients Email

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.

Nursing or Care Home Name (If applicable)

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.

Name

Title

Address(Required)

Address line 1 Address Line 2 City County Postcode Country

What consistency do you require?

Which Slõ Drink would you like to try?(Required)

Which type of sample do you need?(Required)

Keep up to date with News from Slõ Drinks

Sign me up to your newsletter

As you’ve asked for a sample, we will add you to our monthly newsletter to keep you up to date with our developments and others in the dysphagia world.

NOTE: We will NOT contact the Recipient of except in connection with their sample

To ensure you receive them please add info@slodrinks.com to your contacts in Outlook

If you prefer not to receive Slõ News please untick this box.

This field is for validation purposes and should be left unchanged.

Secure Sample Request

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