Download your Just Can't Wait Card | Bladder & Bowel Community

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1Your Details

2Your 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.

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Your Details

Name*

First Name * Last Name *

Email Address*

Telephone*

Date of Birth

Gender

Female

Male

Non-Binary

Postcode*

Opt In

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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 medication

Catheter 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

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

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

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.

Other

Which 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 & Conditions

Agree 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.

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Agree 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.

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OFFICE USE

Comments

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

1Your Details

2Your Condition(s)

Your Details

Name*

First Name * Last Name *

Email Address*

Telephone*

Date of Birth

Gender

Female

Male

Non-Binary

Postcode*

Opt In

Opt 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 medication

Catheter 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

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

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

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.

Other

Which 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 & Conditions

Agree to T&Cs*

Hidden

Agree to T&Cs*

Hidden

OFFICE USE

Phone

This field is for validation purposes and should be left unchanged.

Download your Just Can’t Wait Card

Your Details

Do you use any of the following prescription products?

Do you suffer from any bladder conditions?

Do you suffer from any bowel conditions?

Do you suffer from any other conditions that affect your bladder or bowel?

Which of the following cancers do/have you suffered from?

Terms & Conditions

Your Details

Do you use any of the following prescription products?

Do you suffer from any bladder conditions?

Do you suffer from any bowel conditions?

Do you suffer from any other conditions that affect your bladder or bowel?

Which of the following cancers do/have you suffered from?

Terms & Conditions

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