Title: Mr. Mrs. Ms. Dr.

First Name:

Last Name:

Birthdate:

Address:

2nd Line Address Details:

City:

Postcode:

Email: (if you don’t have an email address please contact us)

Phone:

Phone Type: LandlineMobile

Preferred Method of Contact: PhoneEmailSMS

Delivery Service for Products: Amcare Ltd BCA Direct Brunlea Surgical Bullen Healthcare Group Chemist-Pharmacy Service Clinimed Limited Coloplast Limited Fittleworth Medical Limited Medilink Limited Respond Healthcare Limited Salts Healthcare Securicare Medical Limited Other

Diagnosis for Catheterization: BPH Cancer Endometriosis Mitrofanoff Multiple Sclerosis Spina Bifida Spinal Cord Injury Other

Duration of Catheterization: More than 6 months Less than 6 months

Date of First Catheter use

Number of Catheters Used per Day

Medical History: Please select any that apply Latex AllergyHistory of UTIs

Referring Nurse:

Referring Hospital:

For the purposes of enrolling in Secure Start services, a free consumer service programme, and receiving the associated membership benefits I consent to the processing of my personal identification, communication preferences, health information, product information, third-party information, transactional information and request details by Hollister and its Group Companies (see link below) and its affiliated service company, where applicable. I understand that these services are free of charge, and there is no obligation to purchase anything to receive them. I understand that I am under no obligation to participate in any/all of the applicable membership benefits, such as assistance identifying product supplier options and receiving product samples and other complimentary items. I understand that Hollister, its Group Companies and affiliated product supplier, may communicate with me about consumer services or as part of a membership benefit, using the contact information (postal address, email, phone and SMS text message) that I have provided. Hollister may also share my personal and health information with my healthcare professional, doctor, healthcare product supplier, health insurance provider or other third parties, as indicated in the data privacy notice. Hollister reserves the right to change the consumer service programme at any time.

For the purpose of receiving information about products, promotions and other direct marketing campaigns I consent to the processing of my personal identification, communication preferences, health information and request details, where applicable, by Hollister, includes by the Group Companies thereof (see link below). I understand that Hollister and its Group Companies may communicate with me about these topics, using the contact information (postal address, email, phone and SMS text message) that I have provided.

For the purpose of participating in Hollister's feedback programs, such as surveys, product or service evaluations, and/or clinical trial activities, I consent to Hollister's processing of my name, address, contact information (such as: telephone number and e-mail address), age/birthday, gender, and medical information, which consists of data related to my health and necessary to ensure the suitability of my participation (such as: mobility, type of surgery, product usage, skin conditions, lifestyle), where applicable, for this purpose. As used above, "Hollister" refers to Hollister and its Group Companies (see link below).

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Consent Information