Intermittent Catheter Prescription Upload

Because intermittent catheters are a prescription product, we require verification of a valid intermittent catheter prescription before we can send samples. We will review the information you provided and contact you, or your doctor, if additional information is required.

 
Upload Photo Here*
 
 
 
 
 
 
First Name*
 
 
Last Name*
 
 
 
Email Address*
 
 
 
 
 
 
 
 
 
 

If you are having trouble loading your file, or have any additional questions, please contact us at GC-US@convatec.com or call 1-800-422-8811. 

Your privacy is important to us. By submitting your information, you agree to ConvaTec's privacy policy, available by clicking here.* You may withdraw this authorization by contacting us directly.