Request Free Samples of GentleCath™ 
Intermittent Catheters

Please provide your contact information
First Name*
Last Name*
Phone Number*
Phone Type
Email Address*
Check this box if you are a Healthcare Professional.
Shipping address
Address 2
Zip Code*
VA Healthcare Facility
Facility Name*
Facility Phone Number
Doctor's Full Name
Catheter information
FR Size
Tip Design
Are you a current or recently prescribed intermittent catheter user?*

A valid prescription is required in order to sample intermittent catheter products.
No payment information required.

By submitting your information, you are agreeing to ConvaTec's Privacy Policy and Health Information Consent Policy. If you would like to order ConvaTec's products, you authorize ConvaTec to identify and transfer you to a designated ConvaTec retailer. 
I agree to the above privacy statement.*
You authorize ConvaTec to call, email, text or mail you information about ConvaTec's products and services. You may withdraw this authorization by contacting us at 1-800-422-8811,, or by mail at PO Box 270603, Oklahoma City, OK 73137. 
I agree to the above marketing statement.