Patient's Catheter Sample Request

Thank you for your interest in MTG Catheters. In order to receive your free product sample, please enter the required information below. A representative from MTG will contact you shortly to verify your information and ship the samples to you. We value your feedback. Once you’ve had a chance to try the samples, we will be following up with you again to get your impression of this new product. RX note – Caution: Federal (USA) law restricts this device to sale by or on order of a physician.

Product*
Size and Length (Inches)*
Requested Product(s)
Packaging Style  
[If requesting multiple product samples, please separate the stock numbers with a comma.]
First Name*
Last Name*
Street Address*
[PO boxes are not acceptable addresses as UPS does to deliver to PO boxes.]
City*
State*
Zip Code*
Country*
Phone Number*
Fax Number
E-mail Address*
Current Product
Manufacturer
Stock Number
Where do you buy your current product?
Name of Retailer
City/State
Has your doctor prescribed intermittent catheters for you?*     Yes    No
What is your doctor's name, address and phone number?*     
What insurance do you have?
How did you hear about us?*
Questions/Comments
* Indicates required field