Pee Pouch Samples

1

Your Name* This field is required.

First Name

Last Name

2

Email* This field is required.We'll use this to communicate with you about your samples

example@example.com

3

Date of birth* This field is required.

4

6

How much urine do you usually leak (whether you wear protection or not)?* This field is required.

A large amount

A moderate amount

A small amount

None

7

How much bladder leakage interferes with your regular life?* This field is required.

No interference

Minor interference

Moderate interference

Major interference

8

When does urine leak?* This field is required.

Never - does not leak

Before I can get to the toilet

When I cough or sneeze

When I am sleeping

When I am physically active

When I finished urinating and am dressed

For no obvious reason

All the time

9

Which insurance(s) do you have?* This field is required.

Medicare only

Medicare Advantage only

Medicare + Supplemental Insurance

Medicaid only

Private Insurance only (non-medicare advantage)

No Insurance

10

What's your primary Insurance plan name?* This field is required.e.g Medicare Classic, Humana, Anthem, Blue Shield

11

What's your insurance plan ID?* This field is required.We'll need this to verify your insurance benefits.