Order Supplies

Veuillez remplir le formulaire ci-dessous afin que l’on puisse vérifier si votre couverture d’assurance comprend les fournitures de cathétérisme, ou si vous êtes admissible à un programme de financement public. Sur réception du formulaire, l’un de nos spécialistes communiquera avec vous dans les 2 jours ouvrables pour discuter de vos besoins en matière de produits et des options de financement qui s’offrent à vous.

Contact Info

Patient First Name*

Patient Last Name*

Email*

Phone Number*

Date of Birth

Confirm Email*

If you are a current customer and wish to repeat your last order, please check this box and click submit

If you are a current customer and wish to alter your last order, please specify the changes below and click submit

Shipping Information

Shipping Address Line 1

Shipping Address Line 2

City

Province

Postal Code

Signature required upon product arrival

When checking this box, a charge of $5 will be added to your order

Prescription Information

Doctor/Healthcare Provider Name

Doctor/Healthcare Provider Phone Number

Insurance Information

By checking this box, I provide consent for CathetersPLUS to contact my insurance provider

Yes

Insurance Provider

Primary Policy Holder

Upload Insurance Card

Group Number

ID Number

Customer Service Phone Number

Secondary Insurance (if applicable)

Insurance Provider

Secondary Policy Holder

Upload Insurance Card

Group Number

ID Number

Customer Service Phone Number

Who referred you to CathetersPLUS ?*

Physician

Nurse

Other

Ce champ devrait être laissé vide

Commander des fournitures

Order Supplies

Title

Demeurez en contact avec CathetersPLUS