Order your SpeediCath® samples

For catheter users - please fill out the form below.

If you are a Healthcare Professional, please order your samples on our HCP order form

Because intermittent catheters are a prescription product, we require verification of a valid intermittent catheter prescription before we can send samples. Please be sure to provide your catheter supplier and/or clinic information when requesting samples so that we may verify your prescription on your behalf.

First name:*

Last name:*

Address:*

City:*

State:*

Zip code:*

Email address:*

Phone number:*

Is this a cell phone or a land line? *Cell phone
Land line

Who makes your current catheter product?

If other, please specify:

Catheter French size:

To get your samples faster, please provide your birthdate and supplier and/or clinic information so that we can confirm your prescription on your behalf.

Date of birth (MM/DD/YYYY):

Who is your catheter supplier?

Name of clinic:

Name of prescribing doctor or nurse:

Clinic phone number:

Please help confirm my catheter prescriptionI give Coloplast my consent to contact my supplier, clinic, doctor or nurse to confirm my catheter prescription.

Coloplast Confirmation of Consent

I agree that Coloplast may use, process, and store the information I have entered, including my sensitive health data, to provide product information, as well as education and support as necessary. If applicable, the information may also be shared with a health care provider or medical equipment company to help order supplies, or with Coloplast’s affiliated companies, who may reach out regarding products and related supplies. Coloplast may reach out by phone, including to a cell phone if I provide that number, by text message, e-mail, or mail. Consent may be withdrawn at any time by e-mailing privacyrequests@coloplast.com. I acknowledge and agree that I have read and agree to the Coloplast Declaration of Consent

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Important Safety Information

SpeediCath^® catheters are prescribed for use by pediatric patients (neonates to age 21) and adults who require bladder drainage due to chronic urine retention or post void residual volume (PVR). Before use, carefully read all of the instructions. Call your doctor if you think you have a UTI or can't pass the catheter into the bladder. For more information regarding risks, potential complications and product support, call Coloplast Corp. at 1-866-226-6362 and/or consult the company website at www.coloplast.us.

Questions?

If you have questions, or prefer to speak to a Coloplast representative, please call us at 1-855-605-7588

Headline

Order your SpeediCath® samples

For catheter users - please fill out the form below.

Coloplast Confirmation of Consent

Important Safety Information

Questions?

Thank you for your order