Clinical Context Which intravesical therapies do you currently administer? Hyaluronic Acid / GAG therapy DMSO Antibiotics Lidocaine Heparin Botox Chemotherapy (Mitomycin / Gemcitabine) Other What is your current primary method for instillation? Intermittent catheterization Other (please specify) Which patient types do you treat most frequently? Interstitial Cystitis / BPS Recurrent UTI Post-TURBT chemotherapy Neurogenic bladder Other What interests you most about evaluating UroDapter®? Reducing catheterization Improving patient comfort Reducing infection risk Faster clinic workflow Patient self-administration potential Research interest Professional Profile First Name Last Name Professional Title Select MD DO NP PA RN Other Specialty Select Urology Urogynecology Pelvic Floor Continence Specialist Other Practice / Hospital Name Department Practice Type Select Academic Medical Center Hospital Private Urology Clinic Urogynecology Clinic Outpatient Procedure Center Approximate bladder instillations per month Select 1-10 10-25 25-50 50+ NPI Number Required for U.S. Sunshine Act compliance State Medical License Number Shipping Information Shipping Contact Name Shipping Email Address Country State City Zip Code Shipping Address Line 1 Shipping Address Line 2 How did you hear about UroDapter®? Select Conference Colleague Distributor Journal LinkedIn Direct mail Other If you are interested in conducting a product trial and would like a larger quantity of free samples, please check this box, and add details in the additional notes. Additional Notes I confirm that I am a licensed healthcare professional and that samples are requested for clinical evaluation purposes only. I've read and accept the privacy policy. Request Sample Pack