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Free Sample Request

For a FREE sample request of the Sure SealTM Rings, please fill out the form below, and then click submit.

By submitting this form, you agree to be contacted by Active Lifestyle Products via phone or email.

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First Name *
Last Name *
Email *
Home Phone *
Alternate Phone
Address *
City *
State*
Zip Code *
Manufacturer *
Other Manufacturer
Item number of the flange *
Appliance type *
Where did you hear about the Sure SealTM Rings? *
Where do you purchase your Ostomy supplies? *
Who is your ET Nurse?
Additional Comments
I am a Healthcare Professional
* Indicates Required Fields


First Name *
Last Name *
Email *
Home Phone *
Alternate Phone
Address *
City *
Province*
Postal Code *
Manufacturer *
Other Manufacturer
Item number of the flange *
Appliance type *
Where did you hear about the Sure SealTM Rings? *
Where do you purchase your Ostomy supplies? *
Who is your ET Nurse?
Additional Comments
I am a Healthcare Professional
* Indicates Required Fields

US Resident
Canadian Resident