Please complete the form below to claim your free hand sanitiser
First Name*
Last Name*
Street Address*
Suburb*
State*
Post Code*
Country*
Phone Number*
Email*
Please select the continence products you are currently using*:
SpeediCath Standard
SpeediCath Flex
SpeediCath Compact
SpeediCath Compact Plus
SpeediCath Compact Set
EasiCath
Self-Cath (women)
Self-Cath (man)
I also use another brand of catheter
None
What types of funding do you have for your catheters*?
CAPS (Australia- National)
NDIS: NDIA-Managed (Australia- National)
NDIS: Plan-Managed (Australia- National)
NDIS: Self-Managed (Australia- National)
NDIS: Unknown Management Type (Australia- National)
DVA (Australia- National)
ACC (New Zealand- National)
DHB (New Zealand- National)
TAC (VIC)
NIISQ (QLD)
I Care (Lifetime Care and Support) (NSW)
ENABLE (NSW)
SWEP (VIC)
MASS (QLD)
CMASS (WA)
CES (TAS)
Workcover
No funding
Other
Order consent declaration
By providing your personal and sensitive data, you are consenting to Coloplast that we may process and store your data for the purposes to fulfill your request and to keep you informed about it via phone, text, email, or post. We may share your data with our sub-vendors when necessary to fulfill the request and transfer data securely outside of Australia to support our business operations. You may withdraw consent at any time without ramifications, by writing to privacyrequests@coloplast.com or calling us at 1800 653 317. For more information, please visit our
privacy policy for consent
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