Patient Sample Request Form

If you are a healthcare professional inquiring about the PerfIC Cath Hybrid and would like more information or samples, please follow the link to complete a contact form. HEALTHCARE PROFESSIONALS>>

If you are a patient/user and would like to receive a sample, please fill out the form below.

Name *

Mailing Address *

City *

State *

Zip Code *

Phone *

Email *

I prefer to be contacted by

Phone

Email

Diagnosis

Spinal Cord Injury

Multiple Sclerosis

Spina Bifada

Other

History of UTI?

Yes

No

Would you like to request a sample of the PerfIC Cath Hybrid?

Yes

No

Name of doctor that prescribes current catheter *

Current Distributor

Type of Insurance (Medicaid, Medicare, Private etc.)?

How did you learn/hear about the PerfIC Cath Hybrid?

Please list any additional questions, comments or requests

Release Statement: I acknowledge that if required I could obtain a prescription for the requested samples. *

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