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

First Name*

Last Name*

Contact Number*

*Home Address

*State/ territory

*Postcode

Please support me with the following services

Coloplast Care (lifestyle support for intermittent catheter users including funding options)Enroll me into Coloplast Care

Clinical Nursing Services to support with (select all that apply)Intermittent Self-Catheterisation
Transanal Irrigation
Collecting Devices: Urisheaths and Urine Bags

Coloplast Care Direct (order Coloplast continence products direct)Call me to discuss ordering direct through Coloplast

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 timeYes
No

Support Services declaration of consent By providing your personal and sensitive data, you are consenting to Coloplast that we may process and store your data for the purposes to provide tailored nursing services and healthcare guidance on a regular basis; to fulfill your request and to keep you informed about it in person or by phone, text, email, or post. We will also process your data to improve our products and services and may refer you to healthcare professionals if needed. We may share your data with our sub-vendors when necessary to fulfill the request and transfer data securely outside Australia to support our business operations. You may withdraw consent at any time without ramifications by writing to privacyrequests@coloplast.com or calling us at 1800 653 317. For more information, please visit our privacy policy for consent.

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Headline

Continuing your Continence Care

Your details

Please support me with the following services

Thank you for your order