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. 

Patient details


Clinician details

*The patient listed above has given their consent for me to provide their details for the purpose of delivering Coloplast services.
Please arrange a sample kit to be sent to


Please support my patient 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)
Please indicate the key reasons for referral for nursing support services (select all that apply)


Intermittent Catheters

A maximum of 30 catheters per person in total will be sent  

SpeediCath Compact

SpeediCath Compact Set


SpeediCath Flex/Flex Set (33cm)





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


Leg Bags

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

Sterile Leg Bags: for use with indwelling catheters


Overnight Bags

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

Sterile Overnight Bags: for use with indwelling catheters



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 You may also contact us on +61 9541 1111.


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Thank you for your order


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