Continuing your Continence Care

Referral form

Please note, for referrals with samples requested, kits are sent with product information and continence education materials.

Please note – maximum units per kit is for multiple codes selected. If only one product code is selected the total number of units per kit sent may be lower.

*Required fields

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

Coloplast Pty Ltd collects personal information about your patient, including information about their health or a relevant medical condition. The information we collect may be used to determine which Coloplast products and services are suitable for them and contacting them with further information about these products and services. If we do not collect this information from you, we may not be able to provide them with information about suitable Coloplast products and services. When we first speak to the patient, we will ensure that they also agree with this statement. Further detail about how we collect, use and disclose personal information is available in our Privacy Policy at www.coloplast.com.au/Global/Privacy-policy. You may also contact us on +61 9541 1111.

Patient details
*First name	*Last Name
*Address	*Suburb/City
*State	*Postcode
Email address	*Phone number

Clinician details
*First name	*Last name	Phone number
*Organisation	If other - please specify:	Address
Suburb/City	State	Postcode
*The patient listed above has given their consent for me to provide their details for the purpose of delivering Coloplast services.Yes	Please arrange a sample kit to be sent toPatient's Home Facility

Please support my patient with the following services
Coloplast Care (lifestyle support for intermittent catheter users including funding options)Please 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 assist my patient with ordering direct
	Please indicate the key reasons for referral for nursing support services (select all that apply)Product Review Product Training Technique Review Peristeen Support Program (post initiation support)

Intermittent Catheters
A maximum of 30 catheters per person in total will be sent
LujaLuja Male CH08 D/loop - 20058 Luja Male CH10 D/loop - 20061 Luja Male CH12 D/loop - 20062 Luja Male CH14 D/loop - 20064 Luja Male CH10 S/loop - 20031 Luja Male CH12 S/loop - 20032 Luja Male CH14 S/loop - 20034 Luja Male CH16 S/loop - 20036 Luja Male CH18 S/loop - 20038	SpeediCath CompactSpeediCath Compact Female (7cm) 10Fr - 28580 SpeediCath Compact Female (7cm) 12Fr- 28582 SpeediCath Compact Female (7cm) 14Fr - 28584 SpeediCath Compact Plus Female (9cm) 10Fr - 28810 SpeediCath Compact Plus Female (9cm) 12Fr - 28812 SpeediCath Compact Plus Female (9cm) 14Fr - 28814 SpeediCath Compact Male (30cm) 12-18Fr - 28692	SpeediCath Compact SetSpeediCath Compact Set Female 12Fr/750mL - 28522 SpeediCath Compact Set Male 12-18Fr/750mL - 28422
SpeediCathSpeediCath Paediatric 6Fr - 28706 Standard Paediatric 8Fr - 28708 SpeediCath Female 10Fr - 28510 SpeediCath Female 12Fr - 28512 SpeediCath Female 14Fr - 28514 SpeediCath Male 10Fr - 28410 SpeediCath Male 12Fr - 28412 SpeediCath Male 14Fr - 28414 SpeediCath Male 16Fr - 28416 SpeediCath Male 18Fr - 28418 SpeediCath Male Tiemann Tip 12Fr - 28492 SpeediCath Male Tiemann Tip 14Fr - 28494 SpeediCath Male Tiemann Tip 16Fr - 28496	SpeediCath Flex/Flex Set (33cm)SpeediCath Flex Set 10Fr - 28931 SpeediCath Flex Set 12Fr - 28932 SpeediCath Flex Set 14Fr - 28934 SpeediCath Flex Set 16Fr - 28936 SpeediCath Flex double loop 10Fr - 28910 SpeediCath Flex double loop 12Fr - 28912 SpeediCath Flex double loop 14Fr - 28914 SpeediCath Flex single loop 10Fr - 28920 SpeediCath Flex single loop 12Fr - 28922 SpeediCath Flex single loop 14Fr - 28924 SpeediCath Flex single loop 16Fr - 28916	Self-CathSelf-Cath Paediatric (25cm) 6Fr - 50441 Self-Cath Paediatric (24cm) 8Fr Lure End - 50442 Self-Cath Paediatric (24cm) 10Fr Lure End - 50443 Self-Cath Female (16cm) 10Fr - 50461 Self-Cath Female (16cm) 12Fr - 50462 Self-Cath Female (16cm) 14Fr - 50463 Self-Cath Male (38cm) 10Fr - 50451 Self-Cath Male (38cm) 12Fr - 50452 Self-Cath Male (38cm) 14Fr - 50453 Self-Cath Male (38cm) 16Fr - 50454 Self-Cath Male (38cm) 18Fr - 50455
EasiCathEasiCath Female 8Fr - 5368 EasiCath Female 12Fr - 5372 EasiCath Female 14Fr - 5374 EasiCath Male 10Fr - 5350 EasiCath Male 12Fr - 5352 EasiCath Male 14Fr - 5354 EasiCath Male 16Fr - 5356 EasiCath Male 18Fr - 5358

Urisheaths/Uridomes
A maximum of 7 sheaths per person in total will be sent along with the bag options selected
Conveen Security+ urisheathConveen Security+ Standard (8cm) 21mm - 5221 Conveen Security+ Standard (8cm) 25mm - 5225 Conveen Security+ Standard (8cm) 30mm - 5230 Conveen Security+ Standard (8cm) 35mm - 5235 Conveen Security+ Standard (8cm) 40mm - 5240 Conveen Security+ Short (5cm) 21mm - 22011 Conveen Security+ Short (5cm) 25mm - 22012 Conveen Security+ Short (5cm) 30mm - 22013 Conveen Security+ Short (5cm) 35mm - 22014

Leg Bags
A maximum of 1 leg bag will be sent
Non-sterile Leg Bags: for use with urisheathsConveen Security+ Leg Bag (30cm/500ml) - 5160 Conveen Security+ Leg Bag (50cm/500ml) - 5161 Conveen Security+ Leg Bag (30cm/750ml) - 5166 Conveen Security+ Leg Bag (50cm/750ml) - 5167 Simpla Profile Leg Bag (50cm/500ml) - 21584/2460431	Sterile Leg Bags: for use with indwelling cathetersConveen Security+ Leg Bag (30cm/500ml) - 51621 Conveen Security+ Leg Bag (50cm/500ml) - 51631 Conveen Security+ Leg Bag (30cm/750ml) - 210171 Conveen Security+ Leg Bag (50cm/750ml) - 210181 Simpla Profile Leg Bag (6cm/500ml) - 21573/2460414 Simpla Profile Leg Bag (25cm/500ml) -21574/2460422 Simpla Profile Leg Bag (6cm/750ml) - 21593/2460449 Simpla Profile Leg Bag (25cm/750ml) - 21594/2460457
Overnight Bags
A maximum of 1 overnight bag will be sent
Non-sterile Overnight Bags: for use with urisheathsConveen Non-sterile Leg Bag (30cm/500ml)/straps - 5160/50501 Conveen Non-sterile Leg Bag (50cm/500ml)/straps - 5161/50501 Simpla Non-sterile Night Bag (100cm/2000ml) - 21802	Sterile Overnight Bags: for use with indwelling cathetersConveen Sterile Leg Bag (30cm/500ml)/straps - 51621 Conveen Sterile Leg Bag (50cm/500ml)/straps - 51631 Simpla Sterile Night Bag (120cm/2000ml) - 340811

Peristeen Anal Plugs
A maximum of 1 anal plug will be sent
Small Large

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Headline

Continuing your Continence Care

Patient details

Clinician details

Please support my patient with the following services

Intermittent Catheters

Urisheaths/Uridomes

Leg Bags

Overnight Bags

Peristeen Anal Plugs

Thank you for your order