Please fill out the form below and we will use your catheter needs and preferences to send the product most suitable for you.
Title: Mr. Mrs. Ms. Dr.
First Name:
Last Name:
Birthdate:
Address:
2nd Line Address Details:
City:
Postcode:
Email:
Phone:
Phone Type MobileLandline
Preferred Method of Contact: PhoneEmailSMS
Are you currently using intermittent catheters? Yes No
Where do you receive your 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
Current Product Manufacturer: New User Hollister Other Manufacturer
Product Number/SKU:
What is the reason for this sample request? New user Issue with current product Running low on supplies Want to try something new Nurse recommendation Peer recommendation My product is discontinued Other
How long will you be using catheters? More than 6 months Less than 6 months
What is the reason you are using catheters? BPH Cancer Endometriosis Mitrofanoff Multiple Sclerosis Spina Bifida Spinal Cord Injury Other
What is your French size? 6 8 10 12 14 16 Unknown
What length do you need? 14 cm- Female 17 cm- Female 20 cm- Female 40 cm- Male Unknown
How many catheters do you use per day?
What is your preferred catheter type? Straight With Bag Compact Compact with Bag
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