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Just Complete This Simple Form And We'll Send You 


(Sorry, USA only. Prescription may be required.)

Complete the information below and press the SUBMIT button to send your request. To move around the form in order, press the tab key. Please be as complete as possible so we can send your samples quickly. If you need help filling out this form, we will be happy to take your request by calling us at:  In Hampstead call 270-2200 -  Outside Hampstead, Toll-Free 888 270-2353   Mon- Thurs.. 9 a.m.-5 p.m    Friday close at noon. EST.

In order to receive your free samples, you must provide us with your mailing address and telephone number, along with the information we ask for below relevant to your request. We may contact you via telephone to verify your request, or if we need further information to determine the appropriate size or type of the product you've requested. Thank you for allowing Heartline Medical offer you our finest services.

Address and Telephone Information.     (required for all requests)            

Street Address
Address (cont.)
Zip/Postal Code
Work Phone
Home Phone
     Current Heartline Medical Customer.


Medical  Information     (required for all sample requests)

    Medical Diagnosis

        Spinal cord injury

        Complete        Incomplete

        Multiple sclerosis    Spina Bifida    Other 

Please specify other medical diagnosis


    Insurance Information

    Please check all that apply to you.

    Cash, Credit Card, No Insurance


    Medicaid  Which State?

    Private Insurance 


    Workers Compensation

    Other State or Gov't Insurance. 

     Please specify type. 


Type of intermittent catheter you are currently using:

Clear or stiff plastic    Soft red rubber    Male catheter (10-16inches long)

Female catheter (6-8 inches long)    Straight tip    Coude taper tip

Coude olive tip    MMG O' Neil kits    


French size of intermittent catheter you are currently using:  


Frequency of Urinary Tract Infections

More than 4/year    1-4/year   Less than 1/year


Do you have a urinary tract infection now? Yes    No

Do you wash and reuse your catheters?      Yes    No


Frequency of Catheterization (indicate maximum)   


Doctor Information (required)

First name:

Last name:

Phone: Area Code    







Do you use intermittent catheters?  

STOP Putting Your Kidneys At Risk!  

Urinary tract infections can lead to serious irreparable kidney damage! 


Our Urological Home Care  Program gives you enough supplies so you'll never have to wash and  reuse dirty catheters ever again plus you get gloves, under pads, antiseptic wipes, lubricant, and even misc. items if needed with no up front costs to you! For more information  Click Here


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14679 US Highway 17 N, Hampstead, 28443

Phone: In Wilmington call 270-2200 -  Outside Wilmington Call Toll-Free 866-791-4261

Mon-Thurs. 9 a.m.-5 p.m.  Fri. 9 a.m.-12:00 p.m.  EST.