Continuing your Continence Care

Continence referral form for Coloplast support services

Patients Details

First Name*

Last Name*

Contact Number*

Home Address

Referring Clinician's Details

First Name*

Last Name*

Clinician's Address

Contact Number*

Email*

Please list the continence product(s) your patient is currently using

Please support my patient with the following services

Coloplast Care (lifestyle support for intermittent catheter users including funding options)Enroll my patient 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)Please arrange samples of the following item(s) to be sent to the patients home (please list below):

Please list samples here:

Privacy Statement and Consent

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.

contactUsBysendUsEmail

Headline

Continuing your Continence Care

Thank you for your order