Patient:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone

Patient's Social Security Number 

Patient's Date Of Birth 

Medical Information

Patient's Doctor  

Phone number with area code  

Insurance Information

Primary Insurance Company 

Insurance Company 

Secondary Insurance Company (if applicable)

Insurance Company 

Product Information

Please tell us what products you use 

What type of Catheter do you use: Please note the reorder number is on the box they come in or an REF number can be found on the wrapping of a new one. In order to serve you better please be specific:

Frequency of Catheterization (indicate maximum)    Choose less than 1/day 1/day 2/day 3/day 4/day 5/day 6/day 7/day 8/day 9/day 10/day 11/day 12/day 13/day 14/day 15/day more than 15/day

What type of under pads do you use?

Small
Medium
Large
Thick
Thin

Do you use Lubricant such as KY-Jelly or Surgi-lube?

Yes No
Do you prefer 4 ounce tube or gram packs?  

 

Type of gloves you use::

Powder-free
Latex-free
What size glove do you use?   Small/Medium/Large  
Does the patient have latex allergies Yes/NO?  

Type of diapers: If you don't use diapers just put none:

Do you use antiseptic wipes?

Yes No

 

 Do you use any miscellaneous items?

 Please list items with brand names, size, and reorder numbers if possible!