HCP Request

Healthcare Professional

To request free of charge stock or more information on our products and services, please complete the below form.

For a call back from your local representative, please use the contact us form.

Alternatively, if you would like to register a patient on Emerald please follow this link.

About You

Name

Hospital Address

Postcode

Telephone

Please confirm you are a Healthcare Professional

Yes

Product

Softima Key Base Plate

Softima Key Pouch

Softima Key Quantity

_________________________

Softima 3S Base Plate

Softima 3S Pouch

Softima 3S Quantity

Multiple Choice:

Urimed 2 Litre Bag (UroSilk) Flow Collector 2 Litre Bag (High Flow)

If you would like to order additional stock or cannot find your product in the drop down lists above please enter a description and quantity here:

Please send supporting literature with this stock

Yes

Comment/ Delivery Instructions:

The personal data you provide on this request form (name, hospital address, telephone, email) will be collected and stored in accordance with the requirements of the Data Protection Act 2018.

B. Braun will not share your personal data with any third party. In providing your personal data you consent for such data to be used for the purpose of dealing with your request and providing the service.

Please see the detailed Privacy Policy on our website: https://www.bbraun-emerald.co.uk/en/privacy-policy.html

You can alter your personal data preferences or unsubscribe from the service at any time by sending an email to emerald.bbmuk@bbraun.com.

HCP Request

Healthcare Professional

About You

Product

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