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PATIENTS & CAREGIVERS
PATIENT SERVICES
ABOUT

HEALTHCARE PROFESSIONALS
PATIENTS & CAREGIVERS
PATIENT SERVICES
ABOUT

HEALTHCARE PROFESSIONALS
PATIENTS & CAREGIVERS
PATIENT SERVICES
ABOUT

Sample Request

HR HealthCare Sample Request

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Sample Request

Select a product

Select a packaging configuration:*

20 g Packet with SafeWrap® Package

20 g Packet, Sterile

20 g Packet, Non-Sterile

32 g (1.13 oz.) FlexPac® Pouch

60 g Flip-Top Tube

250 ml (8.5 oz.) Bottle

Select a packaging configuration:*

20 g Packet with SafeWrap® Package

20 g Packet, Sterile

20 g Packet, Non-Sterile

32 g (1.13 oz.) FlexPac® Pouch

250 ml (8.5 oz.) Bottle

Select a packaging configuration:*

8.5 oz. Bottle with Dispensing Cap, Non-Sterile

4 oz. Flip-Top Bottle, Non-Sterile

8 oz. Trigger Spray Bottle, Non-Sterile

16 oz. Trigger Spray Bottle, Non-Sterile

16.9 oz. Dispensing Cap Bottle, Non-Sterile

990 ml Instill/Spikeable Bottle, Non-Sterile

500 ml Instill/Spikeable Bottle, Non-Sterile

250 ml Instill/Spikeable Bottle, Non-Sterile

Select a packaging configuration:*

General Purpose Sterile 5” x 48” (13 x 122 cm)

General Purpose Sterile 6” x 48” (15 x 122 cm)

Intraoperative Sterile 5” x 96” (13 x 244 cm)

Intraoperative Sterile 6” x 96” (15 x 244 cm)

Select a configuration:*

Male External Catheter Sizing Guide

Standard Adhesive 25 mm

Standard Adhesive 29 mm

Standard Adhesive 32 mm

Standard Adhesive 36 mm

Standard Adhesive 41 mm

Extended Adhesive 25 mm

Extended Adhesive 29 mm

Extended Adhesive 32 mm

Extended Adhesive 36 mm

Extended Adhesive 41 mm

Name*

First Last

Facility name (optional)

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

French size*

Length*

Adhesive*

Volume*

Bag Volume*

Size*

Select the number of urinary tract infection(s) in the past year?*

What purpose/procedure(s) are you using this gel for?*

Who are you currently receiving your supplies from?

What is your insurance?

What product are you currently using?

How many times per day are you cathing?

Reason for interest*

Additional comments

Note: product samples may require a valid prescription. No payment information is required.

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Sample Request

HR HealthCare Sample Request

Sample Request

Corporate Headquarters: 2600 Eastern Blvd., Suite 201, York, PA 17402

Manufacturing Facility: 3630 Concord Rd York, PA 17402

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