Continence Care patient order form - Coloplast

Continence Sample Kit - samples to be sent to the patient

Please select the required product(s) and enter both the patients and your details below.

All kits are sent with product information and continence education materials.

*Required fields

Intermittent Catheters

  
A maximum of 10 catheters per person in total will be sent  
SpeediCath Compact Set

SpeediCath Compact






SpeediCath Flex (33cm)






SpeediCath









EasiCath







Self-Cath













Urisheaths/Uridomes

  
A maximum of 7 sheaths per person in total will be sent along with the bag options selected  
Conveen Optima urisheath








  



Drainage Bags

  
A maximum of 1 leg bag and 1 overnight bag will be sent   
Non-sterile Leg Bags: for use with urisheaths




Sterile Leg Bags: for use with indwelling catheters







 
Non-sterile Overnight Bags: for use with urisheaths


Sterile Overnight Bags: for use with indwelling catheters


 



Peristeen Anal Plugs

  
A maximum of 1 anal plug will be sent   


  



Patient details

  
 
 
 
 
Is the condition short term or long term?*

Does the patient receive funding?*




 
Please select the condition this patient requires continence products for:




 
 *Note, our continence department no longer offers Releen samples. Sample orders will now be made through our urology team. Click here to request a Releen sample. 



Clinician details

  
 



*Send kit to

Coloplast Care Direct

A better way to order your Coloplast continence products
 
Please invite this patient to join the Coloplast Care program for intermittent catheter users
My patient is interested in finding out more about Coloplast Care Direct
 

  
  
   

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Free sample - Free shipping

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