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Headline

SpeediCath® sets the standard for quality catheters with innovative and compact solutions in a range of models and sizes for men and women.

Request your free SpeediCath^® samples today!

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 address:*

Phone number:*

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

Which SpeediCath products would you like to try? (Please select all that apply)*SpeediCath® Compact Set
SpeediCath® Compact Male
SpeediCath® Compact Female

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

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 Consent may be withdrawn at any time by e-mailing privacyrequests@coloplast.com.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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*All of these SpeediCath^® users have received compensation from Coloplast to provide this information. Each person’s situation is unique so your experience may not be the same. Talk to your healthcare provider about whether this product is right for you.

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Headline

SpeediCath® sets the standard for quality catheters with innovative and compact solutions in a range of models and sizes for men and women.

SpeediCath® Compact Set

SpeediCath® Compact Female

SpeediCath® Compact Male

Request your free SpeediCath® samples today!

Coloplast Confirmation of Consent

Thank you for your order

Request your free SpeediCath^® samples today!