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Patient Urinary Care Sample request

Urology- Sample Request Form For Patients

The following samples will be free of charge. Normal Actreen® sample size is 5 of each product. However if you select 4 or more different types per order, we will send 3 of each product. Urimed® sample is one per item.*

Fields marked with an asterisk are required.

Salutation

Mr. Mrs. Neutral

First Name *

Last Name *

Type

Email *

Street *

Postal Code *

City *

State *

Country *

Mobile Phone

What insurance do you have? *

To choose more than one product in the same category, press ctrl and click.

Mini Cath (Female) 9cm

Mini Set (Female) 9cm 700ml

Female 20cm

Male straight tip 41 cm

Tiemann Male 41cm

Unisex straight tip set 37 cm, 1 L

Male Tiemann tip set 37 cm, 1 L

Paediatric Set

Indwelling silicone straight tip

Indwelling silicone Tiemann tip

Adult Urine Leg Bags

Urine Drainage Bag Accessories

Night and Day Drainage

Catheter fixation

Your Request

Marketing Permission

Yes, I would like to receive additional information about relevant therapies, products, solutions or events from B. Braun and its contracted distribution partners in future.

B. Braun Australia is the responsible organisation

The protection of the personal data of our customers is very important to us and we take it very seriously. Your personal data is subject to data protection and the collection and storage is subject to Australia Privacy Laws and our Privacy Policy. Under no circumstances will we pass on your personal data to third parties outside of the B. Braun Group or use or store them for any other purposes. Our staff has been trained to handle personal data and is obliged to comply with the data protection regulations.

Data Protection

I have read the data protection policy and agree with processing of my personal data according to the data protection policy. I can cancel this approval at any time.

Urology- Sample Request Form For Patients

To choose more than one product in the same category, press ctrl and click.

Thank you very much for your request!

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