*required fields

First Name*

Last Name*

Email*

Phone Number* (11 digit numbers starting with 0. E.g. 0XXX XXX XXXX)

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?* CH 08CH 10CH 12CH 14CH 16

Address*

City*

Post Code*

Address 2

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

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

Date of Birth* (DD/MM/YYYY)

Which company currently sends or delivers your supplies?* AmcareBullensCharterEmeraldFittleworthLocal PharmacyMedilinkRespondSelectOther

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.

Salutation* Mr.Mrs.Miss.Ms.

County

Product Type* With bagWithout bag

Comments