Order Supplies

Complete the form below to verify your eligibility to receive catheter supplies covered by your insurance provider or via other provincial funding mechanisms. Once we have received your information, one of our specialists will call you within 1-2 business days to discuss your product needs and funding options.

Contact Info

Patient First Name*

Patient Last Name*

Email*

Phone Number*

Date of Birth

Confirm Email*

If you are a current customer and wish to repeat your last order, please check this box and click submit

If you are a current customer and wish to alter your last order, please specify the changes below and click submit

Shipping Information

Shipping Address Line 1

Shipping Address Line 2

City

Province

Postal Code

Signature required upon product arrival

When checking this box, a charge of $5 will be added to your order

Prescription Information

Doctor/Healthcare Provider Name

Doctor/Healthcare Provider Phone Number

Insurance Information

By checking this box, I provide consent for CathetersPLUS to contact my insurance provider

Yes

Insurance Provider

Primary Policy Holder

Upload Insurance Card

Group Number

ID Number

Customer Service Phone Number

Secondary Insurance (if applicable)

Insurance Provider

Secondary Policy Holder

Upload Insurance Card

Group Number

ID Number

Customer Service Phone Number

Who referred you to CathetersPLUS ?*

Physician

Nurse

Other

This field should be left blank

CathetersPlus Order Supplies

Order Supplies

Title

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