Influencer Template

From catheters to pediatric and adult bladder control supplies, discover the continence care essentials covered by your insurance.

Have your insurance card ready!

Step 1 of 2

Child's First Name

Child's Last Name

Child's Date of Birth

Date

Month

Day

Year

Phone

State

Zip Code

Child's Insurance Provider

Insurance Provider

Name of Insurance Carrier

Member ID

Child's Medical Condition

Name of Child's Medical Condition

Gender

How did you hear about us?

By checking this box, I provide my consent for Aeroflow Urology or Aeroflow Health to call me, even using an automatic dialer or prerecorded voice, at the number provided. Consent is not a condition of purchase of any goods or services. I also agree to Aeroflow Health’s dispute resolution and binding arbitration policies, its Privacy Policy, as well as its Terms and Conditions.

By checking this box, I provide my consent for Aeroflow Urology or Aeroflow Health to send me recurring text messages at the number provided in relation to account alerts, billing matters, and updates. Message frequency varies. Reply “STOP” to stop at any time. Message and data rates may apply.

Step 2 of 2

THE AEROFLOW