Address and Telephone Information     (required for all requests)            

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Current Med Mall Online Customer.

Medical  Information     (required for all sample requests)

Medical Diagnosis

Spinal cord injury

Complete        Incomplete

Multiple sclerosis    Spina Bifida    Other 

Please specify other medical diagnosis

Insurance Information

Please check all that apply to you.

Cash, Credit Card, No Insurance

Medicare

Medicaid  Which State?

Private Insurance 

HMO

Workers Compensation

Other State or Gov't Insurance. 

Please specify type. 

Clear or stiff plastic    Soft red rubber    Male catheter (10-16inches long)

Female catheter (6-8 inches long)    Straight tip    Coude taper tip

Coude olive tip    MMG O' Neil kits

French size of intermittent catheter you are currently using:   Choose 6 FR 8 FR 10 FR 12 FR 14 FR 16 FR 18 FR 20 FR Unknown

Frequency of Urinary Tract Infections:

More than 4/year    1-4/year   Less than 1/year

Do you have a urinary tract infection now? Yes    No

Do you wash and reuse your catheters?      Yes    No

Frequency of Catheterization (indicate maximum)    Choose less than 1/day 1/day 2/day 3/day 4/day 5/day 6/day 7/day 8/day 9/day 10/day 11/day 12/day 13/day 14/day 15/day more than 15/day

Doctor Information (required)

First name:

Last name:

Phone: Area Code    

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