Continuing your Continence Care


Continence referral form for Coloplast support services


Please select the required service(s) and enter your details below.

You can also call us to complete the referral on 1800 333 317.

*Required fields


Your details

Please support me with the following services

Coloplast Care (lifestyle support for intermittent catheter users including funding options)
Clinical Nursing Services to support with (select all that apply)

Coloplast Care Direct (order Coloplast continence products direct)

Privacy Statement and Consent
From time to time, we at Coloplast would like to let you know about relevant Coloplast products and services; share inspirational stories from other customers; or tell you about forthcoming events via phone, text, email, or post. Our communication to you will be based on the information you provided to us and your preferences and interests, including your heath data. The choice is yours - and as with any of our services, you may opt-out at any time

Support Services declaration of consent


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