First Name:

Last Name:

Email: (Example: name@emailbox.com)

Phone Number: (XXX-XXX-0000)

(Please use the number we have on file for you)

Account Number: (optional)

How many times per day are you cathing on average?

Are you having trouble cathing due to a blockage and if so, would you like to try a Free Coude catheter sample?

Have you had 2 or more Urinary Tract Infections in the last year and if so, would you like to try a Free Closed System Catheter Kit which comes with a drainage bag and will reduce infections?

Please estimate how many days of supplies you have remaining and select from below.

 

Items to reorder:

 
Catheters
Lubrication

If any items such as address, doctor, or insurance has changed, please tell us what has changed and the new information below:


I acknowledge receiving my last shipment. I am nearly exhausted of my supplies, and require that you send my next shipment of supplies when due. I acknowledge receiving the supplier standards, warranty info and training materials. I authorize the company to renew my prescription, to verify my insurance benefits, to contact me, to request and accept the release of my relevant medical records, and to submit claims and claim assignment of payments of medical benefits for items/services provided to me.