Urological Prescription Form
Complete the form below.
Referrer
Referrer Name
Facility/City
Phone Number
Please enter a valid phone number.
Email
example@example.com
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Clinic
Physician's Name
Clinic/City
Phone Number
Please enter a valid phone number.
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Next
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Patient
Medicaid #
Medicare #
Does patient get home health care?
Yes
No
Discharge Date
-
Month
-
Day
Year
Date
Diagnoses
Insurance Company
Insurance Phone Number
Please enter a valid phone number.
Policy #
Group #
Catheter Details
Catheter Type
Intermittent/"In and Out"
Foley
Does patient need automatic shipment?
Yes
No
How often are Catheters needed?
Monthly
Every other month
Quarterly
Order as Needed
Tip Type
Straight
Coudé
Ballon Size
French Size
Please Select
6
8
10
12
14
16
18
20
22
24
Length
6" (typical female)
16" (typical male)
Other Length
If 6" or 16" doesn't work.
Lubricant
Yes
No
Estimated Duration of Need
Frequency of Catherization
How many times per day/month?
Special Requirements
Please Select
Red Rubber
Hydrophilic
Silicone
Other Items
Male External Catheter (condom type)
Enter Quantity
Bedside Drainage Bag
Enter Quantity
Urinary Drainage Bag
Enter Quantity
Other
Submit
Should be Empty: