First Name:

Please enter your first name

Last Name:

please enter your last name

Date of birth:

Please enter a valid date of birth Invalid Date format. Valid Date Format dd/MM/yyyy

Email: (Example: name@emailbox.com)

please enter your valid email address Invalid Email Format

Phone Number: (XXX-XXX-0000)

Please enter a valid phone no. Invalid Phone Number Format

(Please use the number we have on file for you)

Account Number: (optional)

How many times per day are you cathing on average?

Select 1/day 2/day 3/day 4/day 5/day 6/day 7/day

Are you having trouble cathing due to a blockage and if so, would you like to try a Free Coude catheter sample?

Yes

No

Have you had 2 or more Urinary Tract Infections in the last year and if so, would you like to try a Free Closed System Catheter Kit which comes with a drainage bag and will reduce infections?

Yes

No

Please estimate how many days of supplies you have remaining and select from below.

0 (no catheters left) 1 day 2 days 3 days 4 days 5 days 6 days 7 days 8 days 9 days 10 days 11 days 12 days 13 days 14 days 15 days 16 or more days

Items to reorder:

	Catheters
	Lubrication

To update your account information, please click here: https://www.usmed.com/current-patients/change/

You have to agree to our terms before you can reorder. I acknowledge receiving my last shipment. I am nearly exhausted of my supplies, and require that you send my next shipment of supplies when due. I acknowledge receiving the supplier standards, warranty info and training materials. I authorize the company to renew my prescription, to verify my insurance benefits, to contact me, to request and accept the release of my relevant medical records, and to submit claims and claim assignment of payments of medical benefits for items/services provided to me.

Sorry, we couldn't process your request at this time, please call us at 1-866-723-6958 to place your request.