Severity Chart

Complete the following form to receive one free Nampons™ or Nampons™ Kids nosebleed stopper. One per household. United States only.

Free Nampons™ Sample

Sample Request Form

First Name

Last Name

Address

City

State/Province

Zip/Postal

How often do you or the person you are requesting a sample for get nosebleeds?

How old is the person you are requesting the sample for?

If older than 12, a sample of Nampons™ will be sent. If under 12 years old, a Nampons™ Kids sample will be sent.

Have you ever used Nampons™ before for a nosebleed?

Yes

Not Sure

If you are human, leave this field blank.