GeT Your Free Catheters 

Just Complete This Simple Form And I Will Send You 

FREE INTERMITTENT CATHETERS 

(Sorry, USA only. Prescription may be required.)

Complete the information below and press the SUBMIT button to send your request. To move around the form in order, press the tab key. Please be as complete as possible so I can send your catheters to you quickly.

In order to receive your free catheters, you must provide me with your mailing address and telephone number, along with the information I ask for below relevant to your request. I may contact you via telephone to verify your request, or if I need further information to determine the appropriate size or type of the product you've requested. 


Address and Telephone Information     (required for all requests)            

ID# 0747620999

*Name
*Street Address
Address (cont.)
*City
*State
*Zip/Postal Code
Work Phone
Home Phone
*E-mail
    

 

Medical  Information     (required for all sample requests)

    Medical Diagnosis Check all that applies.

        Spinal cord injury

        Complete        Incomplete

        Multiple sclerosis    Spina Bifida    Other 

Please specify other medical diagnosis or level of injury

 

    Insurance Information

    Please check all that apply to you.

    Cash, Credit Card, No Insurance

    Medicare

    Medicaid  Which State?

    Private Insurance 

    HMO

    Workers Compensation

    Other State or Gov't Insurance. 

     Please specify type. 

 

Type of intermittent catheter you are currently using:

Clear or stiff plastic    Soft red rubber    Male catheter (10-16inches long)

Female catheter (6-8 inches long)    Straight tip    Coude taper tip

Coude olive tip    MMG O' Neil kits    

 

French size of intermittent catheter you are currently using:  

 

Frequency of Urinary Tract Infections

More than 4/year    1-4/year   Less than 1/year

 

Do you have a urinary tract infection now? Yes    No

Do you wash and reuse your catheters?      Yes    No

 

Frequency of Catheterization (indicate maximum)   

   

Doctor Information (required)

*First name:

*Last name:

*Phone: Area Code    

 

Comments

 

 


 Free Catheters.
Copyright 2005. All rights reserved.
Revised: May 25, 2006