speedicath male sample form

Order your free SpeediCath® Compact Male sample today!

Request your free samples by filling out the form below or call us at 1-800-231-2371.

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.

* = Required to Complete Sample Request

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):

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

Please check the box to acknowledge that you have read and understood the Confirmation of Consent

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Order your free SpeediCath® Compact Male sample today!

Request your free samples by filling out the form below or call us at 1-800-231-2371.

Coloplast Confirmation of Consent

Thank you for your order

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Order your free SpeediCath® Compact Male sample today!

Request your free samples by filling out the form below or call us at 1-800-231-2371.

Coloplast Confirmation of Consent

Thank you for your order