Order your SpeediCath^® Compact Set samples

Please note that intermittent catheters are a prescription product. If you're requesting a sample of an intermittent catheter we require verification of a valid intermittent catheter prescription before we can send samples.

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Email*

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:

Intermittent catheters are a prescription product. To get your samples faster, please provide your date of birth and supplier and/or clinic information so that we can confirm your prescription on your behalf.

Date of birth (MM/DD/YYYY):

Where do you buy your catheter supplies?

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 Consent may be withdrawn at any time by e-mailing privacyrequests@coloplast.com.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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Order your SpeediCath^® Compact Set samples

Request your free samples by filling out the form below or call us at 1-833-679-0798

Thank you for your order

Headline

Order your SpeediCath® Compact Set samples

Request your free samples by filling out the form below or call us at 1-833-679-0798

Thank you for your order

Order your SpeediCath^® Compact Set samples