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*required fields

First Name*

Last Name*

Email*

Phone Number*

Gender* FemaleMalePrefer not to answer(The catheter has a length of 40cm/16in predominately used by male catheter users)

Who is the manufacturer of your current catheter? BardColoplastCureHollisterLofricOtherI don't know

What size is suitable for you?* VaPro Plus Pocket 8 FrVaPro Plus Pocket 10 FrVaPro Plus Pocket 12 FrVaPro Plus Pocket 14 FrVaPro Plus Pocket 16 FrVaPro Pocket 10 FrVaPro Pocket 12 FrVaPro Pocket 14 FrVaPro Pocket 16 Fr

Address*

City*

Postal Code*

Address 2

How long have you been catheterising?* 0-6 Months7-12 Months1-2 Years2-4 Years4+ YearsI do not currently catheterise

What is the brand name of the catheter you are currently using? ApogeeSpeediCath CompactSpeediCath Compact PlusMagic3 GoOnliSenseTwistOtherI don't know

Province* ABBCMBNBNFNTNUNSONPEQCSKYT

Birthdate* (MM/DD/YYYY)

I want to stay informed about Hollister products and services which may be of interest to me via email, postal mail, telephone, SMS, etc.; I consent to the processing of my name, address, contact information (such as telephone number and e-mail address), gender, and medical information, which consists of data related to my health and useful to identify my direct marketing needs (such as: mobility, type of surgery, length of product usage, skin conditions) for this purpose.

I want to receive samples and related product guide;* I consent to the processing of my name, address, contact information (such as: telephone number and e-mail address) and medical information, which consists of data related to my health and is necessary to identify the correct product (such as: mobility, type of surgery, length of product usage, skin conditions) for this purpose.

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