"*" indicates required fields 1Your Details2Your Condition(s) You’re just a few steps away from your FREE Digital Just Can’t Wait Card! Simply complete your name and a few details about your bladder or bowel condition so that we can suggest the right information and services for you. The Digital Card requires Apple Wallet or Google Wallet to work on your smartphone. Please install prior to download. If you prefer a plastic card, please purchase one via our website here.Your DetailsName* First Name * Last Name * Email Address* Telephone*Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Female Male Non-Binary Postcode*Opt InOpt in to receive news and information from Bladder & Bowel Community, please select your preferences: B&BC Newsletter B&BC Products and Services Relevant Products and Services from B&BC Partners Do you use any of the following prescription products?Question 1 of 4* Stoma Catheters Sheaths Bowel or Rectal Irrigation Systems* None *not including any suppositories or medicationCatheter Type* Suprapubic Indwelling Intermittent What type of Catheter do you use? Which of the following bowel or rectal irrigation systems do you currently use?* Peristeen Qufora Aqua Flush Irypump Navina Do you suffer from any bladder conditions?Question 2 of 4 Yes No Do you suffer from any of the following bladder conditions? Frequency Bladder Incontinence Bladder Incontinence (After Childbirth) Urinary incontinence in children Cystitis Bladder Cancer Urinary Tract Infections Urine Retention Overactive Bladder Other Please tick all that apply.Please state:Do you suffer from any bowel conditions?Question 3 of 4 Yes No Which of the following bowel conditions do you suffer from?* Accidental Leakage from the bowel Constipation Diarrhoea Irritable Bowel Syndrome (IBS) Inflammatory Bowel Disease (IBD) Crohn's Disease Ulcerative Colitis Diverticular Disease Bowel Cancer Bowel Obstruction Fecal Impaction Fecal Incontinence Short Bowel Syndrome Coeliac Disease Other Please tick all that apply.Please state:Do you suffer from any other conditions that affect your bladder or bowel?Question 4 of 4 Yes No Do you suffer from any of the following conditions? Dementia Diabetes Multiple Sclerosis Parkinsons Disease Prostate Problems Spinal Cord Injury Stroke Spina Bifida Brain Injury Cancer Other Please tick all that apply.OtherWhich of the following cancers do/have you suffered from?Do you suffer from any of the following conditions? Breast Prostate Lung Melanoma Skin Cancer Non-Hodgkin Lymphoma Kidney Head and Neck Brain, Other CNS & Intracranial Tumours Pancreas Leukaemia Uterus Oesophagus Ovary Stomach Liver Myeloma Thyroid Cervix Please tick all that apply.Terms & ConditionsAgree to T&Cs* I agree to the terms and conditions and understand all details completed will be passed to the Bladder & Bowel Community. Bladder & Bowel Community may contact you to discuss any additional home delivery support they can provide through Bladder & Bowel Home Delivery. Bladder & Bowel Home Delivery is a joint partnership between Bladder & Bowel Community and Bullen Healthcare. Click here to read our terms and conditions and click here to read our privacy policy. This field is hidden when viewing the formAgree to T&Cs* I agree to the terms and conditions and understand all details completed will be passed to the Bladder & Bowel Community who may contact you to discuss the Bladder & Bowel Catheter Nurse support and services they can provide, Bladder & Bowel Catheter Nurse Service is a joint service between Bladder & Bowel Community and Amcare. Amcare can offer Catheter support and home delivery supplies. Amcare is a part of ConvaTec Group PLC. You may withdraw authorisation at any time by writing or emailing the Bladder & Bowel Community. This will also apply to Bladder & Bowel Catheter Nurse Service and Amcare. Click here to read our terms and conditions and click here to read our privacy policy.This field is hidden when viewing the formOFFICE USECommentsThis field is for validation purposes and should be left unchanged. "*" indicates required fields 1Your Details2Your Condition(s) You’re just a few steps away from your FREE Digital Just Can’t Wait Card! Simply complete your name and a few details about your bladder or bowel condition so that we can suggest the right information and services for you. The Digital Card requires Apple Wallet or Google Wallet to work on your smartphone. Please install prior to download. If you prefer a plastic card, please purchase one via our website here.Your DetailsName* First Name * Last Name * Email Address* Telephone*Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Female Male Non-Binary Postcode*Opt InOpt in to receive news and information from Bladder & Bowel Community, please select your preferences: B&BC Newsletter B&BC Products and Services Relevant Products and Services from B&BC Partners Do you use any of the following prescription products?Question 1 of 4* Stoma Catheters Sheaths Bowel or Rectal Irrigation Systems* None *not including any suppositories or medicationCatheter Type* Suprapubic Indwelling Intermittent What type of Catheter do you use? Which of the following bowel or rectal irrigation systems do you currently use?* Peristeen Qufora Aqua Flush Irypump Navina Do you suffer from any bladder conditions?Question 2 of 4 Yes No Do you suffer from any of the following bladder conditions? Frequency Bladder Incontinence Bladder Incontinence (After Childbirth) Urinary incontinence in children Cystitis Bladder Cancer Urinary Tract Infections Urine Retention Overactive Bladder Other Please tick all that apply.Please state:Do you suffer from any bowel conditions?Question 3 of 4 Yes No Which of the following bowel conditions do you suffer from?* Accidental Leakage from the bowel Constipation Diarrhoea Irritable Bowel Syndrome (IBS) Inflammatory Bowel Disease (IBD) Crohn's Disease Ulcerative Colitis Diverticular Disease Bowel Cancer Bowel Obstruction Fecal Impaction Fecal Incontinence Short Bowel Syndrome Coeliac Disease Other Please tick all that apply.Please state:Do you suffer from any other conditions that affect your bladder or bowel?Question 4 of 4 Yes No Do you suffer from any of the following conditions? Dementia Diabetes Multiple Sclerosis Parkinsons Disease Prostate Problems Spinal Cord Injury Stroke Spina Bifida Brain Injury Cancer Other Please tick all that apply.OtherWhich of the following cancers do/have you suffered from?Do you suffer from any of the following conditions? Breast Prostate Lung Melanoma Skin Cancer Non-Hodgkin Lymphoma Kidney Head and Neck Brain, Other CNS & Intracranial Tumours Pancreas Leukaemia Uterus Oesophagus Ovary Stomach Liver Myeloma Thyroid Cervix Please tick all that apply.Terms & ConditionsAgree to T&Cs* I agree to the terms and conditions and understand all details completed will be passed to the Bladder & Bowel Community. Bladder & Bowel Community may contact you to discuss any additional home delivery support they can provide through Bladder & Bowel Home Delivery. Bladder & Bowel Home Delivery is a joint partnership between Bladder & Bowel Community and Bullen Healthcare. Click here to read our terms and conditions and click here to read our privacy policy. This field is hidden when viewing the formAgree to T&Cs* I agree to the terms and conditions and understand all details completed will be passed to the Bladder & Bowel Community who may contact you to discuss the Bladder & Bowel Catheter Nurse support and services they can provide, Bladder & Bowel Catheter Nurse Service is a joint service between Bladder & Bowel Community and Amcare. Amcare can offer Catheter support and home delivery supplies. Amcare is a part of ConvaTec Group PLC. You may withdraw authorisation at any time by writing or emailing the Bladder & Bowel Community. This will also apply to Bladder & Bowel Catheter Nurse Service and Amcare. Click here to read our terms and conditions and click here to read our privacy policy.This field is hidden when viewing the formOFFICE USEPhoneThis field is for validation purposes and should be left unchanged. Share this story
