3M

™

Medipore

™

/ Medipore

™

H Tape Evaluation Form

____________________________________ ___________________________________ ____________________________

Evaluator Facility & Department Date

____________________________________ ___________________________________ ____________________________

Address Telephone 3M Representative Name

1. Are you currently using a “soft cloth” tape? Yes No

If so, what manufacturer/brand? ____________________________________________________________________________

2. Please tell us what you think of 3M Medipore/Medipore H Tape and compare it to the tape you are currently using for similar applications.

Thank you for participating in the evaluation. Your time and opinions are appreciated!

Please return this form in the postage-paid envelope provided.

P.O. Box 5757

London, Ontario N6A 4T1

3M, Medipore and Medipore H

are trademarks of 3M.

Printed in U.S.A.