Signed Date Date Format: MM slash DD slash YYYY Questions with (*) are required. Are you or a loved one currently using catheters? Are you interested in receiving our Pain Free and No Mess catheters from Trust Home Medical, an American owned and operated company?*Yes, I’m using catheters and I am ready to join Trust Home Medical!I’m using catheters but I just want a free sampleI’m not using catheters but I’m interested in possibly starting.We offer a 100% satisfaction guarantee, that means if you aren't completely satisfied, we will pick them up for free. Want to try something new? We will send you several new choices with your order so you do not run out while we work with you to find what you like the best. What options are you looking at? Pain Free Pre-Lubricated No Mess Travel or Pocket Sized Extra long for use from chair Just something than what I’m using We completely understand. Why do you think you might need to start using catheters? Is it because…You are waking up frequently in the night to use the restroom?You are having accidents and don’t want to wear adult diapers?You are dealing with both of these issues?We see this a lot. As we get older it can be hard to drain our bladder all the way and this can lead to feeling the urge to go to the restroom frequently. This makes it hard to get a good night sleep and leave the house, but don’t worry, using a catheter can alleviate this issue and let you return to a much more stress-free life.Using diapers can be embarrassing, uncomfortable, and expensive. Instead, you can use an external catheter that hides easily under your clothes, traps unwanted smells, and is paid for by your insurance. It is also usually much healthier for you, so let’s get rid of this stress once and for allThis happens more frequently than you might imagine. Sometimes the nerves in our bladder don’t work right so we either feel the urge to go frequently or don’t feel it at all. Usually using a catheter regularly will drain the bladder completely and eliminate both of these problems. Together, we will put this stress behind you. We are excited to have you join our family, where every patient is treated as a person, not just a number. What is the most important benefit from Trust Home Medical for you?American owned and operatedPersonal customer serviceFree Cranberry supplement for lifeFree Samples at any time of the newest cathetersOtherWhat makes our catheters Pain Free? Unique polished eyelets that are designed to glide smoothly and effortlessly. Results may vary, but with the right size and lubrication, you too can be on your way to being Pain-Free.What makes our catheters No Mess? We offer a pre-lubricated option, that has a no-drip, even coverage, no kink technology…we’ll include a sample for free with your first order!Travel catheters are discreet and fit in your pocket or purse easily for when you are on the go. The ones for men are half the length of a standard catheter and for women, they are as small as a tube of lipstick!Moving from a wheelchair or motor scooter can be a real pain and a little scary if you are out in public. These new catheters are 25 inches long so you can stay in your own chair when you cath!Not every catheter is for everyone just like there are different shoes to fit your unique level of comfort and needs. We’ll find out what you are using now, end send you a few different options that are rated the highest in satisfaction by our current patients. So let’s find out who’s looking to get the supplies first…are you completing this on behalf of yourself or someone you love?*MyselfLoved one Patient InformationGot it, the rest of the questions please answer as if you are the patient, but you will put in your information in the Emergency Contact section at the end. What is your name?* First Last For security purposes may we have your date of birth?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 What is your gender?*MaleFemale What is the best way to contact you?* Email Phone Text Can you please provide your email address?*What is the best phone number we can use to contact you?*Do you mind also providing your phone number?*By submitting this information, you authorize Trust Home Medical to contact you regarding your insurance, supplies, or provider information. Trust Home Medical promises to never give out your number or use it for any marketing related reasons. Where should we send your supplies or samples… no PO Boxes please!Contact Address* Street: Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Medical Insurance InformationSo we can make sure the supplies are covered by your insurance at little or no cost to you, can you give us your insurance information?What is your Primary Medical Insurance Provider?*MedicareMedicaidPrivateI'm Paying CashDo you have Traditional Medicare or Medicare Advantage?*Traditional MedicareMedicare Advantage / NontraditionalWhat is your Medicare Member ID#?*Last Entered Medicare IDName* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Invalid Medicare ID. Please make sure the patient name, date of birth and Medicare ID match and are valid.Hidden Approve denyTraditionalNontraditionalInvalidMismatchInternal ErrorMismatch Returned Name First Last Mismatch Returned DOBInternal Error MessageDo you also have Medicare Supplemental, Medicaid, or a Secondary Private Insurance?*Medicare SupplementalSecondary Private InsuranceMedicaidNeither, I only have my Primary InsuranceWhat state is your Medicaid insurance registered for?* StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State What is your Medicaid Member ID#?*This is on your Medicaid card right beneath your name.Which Private Carrier do you have?*Blue Cross Blue ShieldUnited HealthCignaIs this an HMO, PPO, or other type of insurance plan?*HMOPPOOther/I don’t knowWhat is your insurance Member ID#?*What is the name of your Secondary Insurance Carrier?*What is the Member ID for your Secondary Carrier?*It may be listed as a Subscriber ID or Member ID. It is usually the long number on your card.May you please provide the Toll-Free number for your Secondary Carrier?This is usually a 1-800 number found on the front or back of the card. Doctor's InformationBy providing your doctor’s information we can obtain approval to get your supplies delivered to you.Please search for your Doctor using the fields below.Please select your Doctor from the list and click Next below. If your Doctor is not listed, Search Again, or click Cannot Find My Doctor.No Results Found? Click Search Again to keep searching, or click Cannot Find My Doctor to Enter Their InformationPlease enter all of your Doctor’s Information including their phone number found on your most recent medication. When finished click Next at the bottom. You may also Search Again if you’d like.Search TypesearchmanualresultconfirmedResults FoundYesNoEmptySelect Your Doctor Here:*Select DoctorDoctor's First Name*Doctor's Last Name*Office Location City*Office Location State*ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYOffice Location Zip*Doctor's Phone Number*Alternate Doctor's Phone NumberThank you. Please enter your Doctor’s Phone Number found on your most recent medication if it is not the same as the one listed below and please click next.NPI NumberNNPES Full NameNNPES Address StreetNNPES Address City StateNNPES Phone NumberNNPES Fax Number In order to figure out what kind of supplies you are currently using, what is the Reference number on the back of your package of catheters? It will say REF# on the package.Do you know your supplies' reference number?*Yes, I do.No, I don’t.Reference Number*Do you know what kind of catheters you want to use? If you don’t know it is ok, we’ll figure it out together.Based on our questions we asked you at the beginning, we think you should be using an intermittent catheter, where you use it every time you need to use the restroom, does that sound right to you?Yes, keep it as IntermittentNo, I want to pick something elseBased on our questions we asked you at the beginning, we think you should be using an external catheter to keep you from needing diapers, does that sound right to you?Yes, keep it as ExternalNo, I want to pick something elseCatheter TypeIntermittent Straight TipCoudé Tip IntermittentExternal/Condom CatheterFolley/Indwelling or SuprapubicClosed KitClosed Kit with Coudé TipI Don’t KnowAre you suffering from incontinence or retention? Incontinence is usually when you have accidents and retention is usually when you find yourself waking up frequently in the middle of the night to use the restroom.IncontinenceRetentionDoes the catheter you use or are looking for go on like a condom (men) or fit over the outside like a cup (women)?Yes it is ExternalNoIt looks like you use an External/Condom Catheter. Do you have a brand preference?CureColoplastBardHollisterRochesterOtherNo PreferenceDoes the catheter go in and stay in for a long period of time?Yes it is a Foley or IndwellingNoIt looks like you use a Foley/Indwelling Catheter. Do you have a brand preference?CureColoplastBardHollisterRochesterOtherNo PreferenceIs the tip of your/their catheter bent slightly, or straight?BentStraightDoes your catheter come with a complete kit including gloves and other supplies?YesNoIt looks like you use an Intermittent Catheter. Do you have a brand preference?CureColoplastBardHollisterRochesterOtherNo PreferenceIt looks like you use an Intermittent Catheter. Do you have a brand preference?CureColoplastBardHollisterRochesterOtherNo PreferenceIt looks like you use a Coudé Catheter. Do you have a brand preference?CureColoplastHollisterRochesterOtherNo PreferenceIt looks like you use a Coudé Catheter. Do you have a brand preference?CureColoplastHollisterRochesterOtherNo PreferenceIt looks like you use a Closed Kit Catheter. Do you have a brand preference?CureColoplastBardHollisterRochesterOtherNo PreferenceIt looks like you use a Closed Kit Catheter. Do you have a brand preference?CureColoplastBardHollisterRochesterOtherNo PreferenceIt looks like you use a Coude Kit Catheter. Do you have a brand preference?CureColoplastBardHollisterRochesterOtherNo PreferenceIt looks like you use a Coude Kit Catheter. Do you have a brand preference?CureColoplastBardHollisterRochesterOtherNo PreferenceHow many catheters do you use a day123456789101112I Don't KnowHow many catheters do you use a day?12What length of catheter do you use?6"- normal for woman7"- normal for pediatric14"16"- normal for a man25"I Don't KnowWhat is the diameter or french size of your catheter?8fr10fr12fr – most common14fr – common for Foley16fr18fr20frI Don't Know(show color chart here)What size of catheter do you use?23mm XSmall25mm Small30mm Medium32mm Intermediate – most common35mm LargeDon't Know or FemaleDo you use clear plastic or red rubber cathetersClear PlasticRed RubberWhat funnel type do you use?FunnelNo Funnel2-Way Funnel3-Way FunnelI Don't KnowAre you/they allergic to Latex?*YesNoDon’t worry, we have a Latex and DEHP Free catheter just for you!Have you had any Urinary Tract infection (UTI) in the last 12 months?*One timeMore than onceNoOk, we are almost done! We will send a complete 90 day order. Re-ordering is easy, we will call you before you run out so you don’t have to wash and reuse catheters. We take care of billing the insurance and requesting medical records from your doctor. All of this is included FREE with your membership. You understand co-pays and deductibles apply. We are sure you will be completely satisfied, but if want to return the supplies for any reason, just call us within 30 days and we will pick up the unused supplies for FREE. Shipping is always FREE both ways. By submitting below you agree that you understand and authorize this service. CLICK AND DRAG TO SIGN BELOW!* Emergency Contact InformationEmergency Contact Name First Last Emergency Contact Phone NumberThat’s it! Here is what happens now. We’ll confirm with your doctor and insurance before sending you your complete 90-day order along with some FREE catheter samples of our NO MESS catheters.Re-ordering is easy, we will call you before you run out. You understand we will be billing your insurance on your behalf and you will be responsible for any co-pays and deductibles that may apply. We are sure you will be completely satisfied, but if you want to return supplies for any reason, please call us within 30 days and we’ll pick them up.It’s that Easy! I know you are going to like this new service and these new catheters. Thank you for trusting Trust Home Medical!
