Information Request Form - Urostomy Association

Please send me further information about the Urostomy Association.

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Name*

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Address*

Street Address City County Post Code Country

Email*

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I have a urinary diversion
I may need to have a urinary diversion in the future
I am interested in the work of the Urostomy Association because

Type of operation

Urostomy
Bladder reconstruction/neo-bladder
Continent urinary stoma
Rectal bladder

Please state reason

The Urostomy Association DVD

Request a DVD

The Urostomy Association leaflets

Here at the Urostomy Association we take your privacy seriously and will only use your personal information to support you and to provide the products and services you have requested from us. Your personal details will NOT be passed to any third-party.

Data Consent*

I have read the Terms & Conditions and agree to the processing of my data as outlined in the Privacy & Cookie Policy

Name

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