Request your free samples by filling out the form below.

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.

Is this a cell phone or a land line? *

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

Coloplast Confirmation of Consent

Coloplast Confirmation of Consent

Close

Order your free samples

Thank you for your order

Your order is complete!

View desktop version