Order your SpeediCath^® Compact Set samples

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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.

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Who is your catheter supplier?

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

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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 Consent may be withdrawn at any time by e-mailing privacyrequests@coloplast.com.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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*Privacy Statement

Coloplast respects the privacy of your personal information and will protect the confidentiality of the information contained on this form. The only time the information may be used or shared is if it is (1) required by law; or (2) to provide you with information about Coloplast products, services and wellness education. You may be contacted by Coloplast, its agents, affiliates, contractors, or supply or service providers by telephone, email, US Mail, or other means of communication only for the purpose stated above. If you choose not to receive communication from Coloplast, please contact us at 1-888-726-7872 or email unsubscribe-us@coloplast.com to request that communication be discontinued.

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Order your SpeediCath^® Compact Set samples

Coloplast Confirmation of Consent

*Privacy Statement

Thank you for your order

Headline

Order your SpeediCath® Compact Set samples

Coloplast Confirmation of Consent

*Privacy Statement

Thank you for your order

Order your SpeediCath^® Compact Set samples