Continence Care 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 SetCompact Set Female 12Fr/750mL Compact Set Male 12-18Fr/750mL	SpeediCath CompactSpeediCath Compact Female (7cm) 10Fr SpeediCath Compact Female (7cm) 12Fr SpeediCath Compact Female (7cm) 14Fr SpeediCath Compact Plus Female (9cm) 10Fr SpeediCath Compact Plus Female (9cm) 12Fr SpeediCath Compact Plus Female (9cm) 14Fr SpeediCath Compact Male (30cm) 12-18Fr	SpeediCath Flex (44cm)SpeediCath Flex double loop 10Fr SpeediCath Flex double loop 12Fr SpeediCath Flex double loop 14Fr SpeediCath Flex single loop 10Fr SpeediCath Flex single loop 12Fr SpeediCath Flex single loop 14Fr SpeediCath Flex single loop 16Fr
SpeediCathSpeediCath Paediatric 6Fr SpeediCath Female 10Fr SpeediCath Female 12Fr SpeediCath Female 14Fr SpeediCath Male 10Fr SpeediCath Male 12Fr SpeediCath Male 14Fr SpeediCath Male 16Fr SpeediCath Male 18Fr SpeediCath Male Tiemann Tip 12Fr SpeediCath Male Tiemann Tip 14Fr SpeediCath Male Tiemann Tip 16Fr	EasiCathEasiCath Female 8Fr EasiCath Female 12Fr EasiCath Female 14Fr EasiCath Male 10Fr EasiCath Male 12Fr EasiCath Male 14Fr EasiCath Male 16Fr EasiCath Male 18Fr	Self-CathSelf-Cath Paediatric (25cm) 6Fr Self-Cath Paediatric Leur End (25cm) 8Fr Self-Cath Paediatric Leur End (25cm) 10Fr Self-Cath Female (16cm) 10Fr Self-Cath Female (16cm) 12Fr Self-Cath Female (16cm) 14Fr Self-Cath Male (40cm) 10Fr Self-Cath Male (40cm) 12Fr Self-Cath Male (40cm) 14Fr Self-Cath Male (40cm) 16Fr Self-Cath Male (40cm) 18Fr

Urisheaths/Uridomes
A maximum of 7 sheaths per person in total will be sent along with the bag options selected
Conveen Optima urisheathConveen Optima Standard (8.5cm) 25mm Conveen Optima Standard (8.5cm) 28mm Conveen Optima Standard (8.5cm) 30mm Conveen Optima Standard (8.5cm) 35mm Conveen Optima Standard (8.5cm) 40mm Conveen Optima Short (5.5cm) 21mm Conveen Optima Short (5.5cm) 25mm Conveen Optima Short (5.5cm) 30mm Conveen Optima Short (5.5cm) 35mm

Drainage Bags
Non-sterile:Simpla Profile Leg Bag (50cm/500ml)	Sterile:Simpla Profile Leg Bag (6cm/500ml) Simpla Profile Leg Bag (25cm/500ml) Simpla Profile Leg Bag (6cm/750ml) Simpla Profile Leg Bag (25cm/750ml)
Non-sterile: for use with urisheaths (choose x1 leg bag, x1 night bag)Conveen Leg Bag (30cm/500ml) Conveen Leg Bag (50cm/500ml) Simpla Night Bag (100cm/2000ml)	Sterile: for use with indwelling catheters (choose x1 leg bag, x1 night bag)Conveen Leg Bag (30cm/500ml) Conveen Leg Bag (50cm/500ml) Simpla Night Bag (120cm/2000ml)

Peristeen Anal Plugs
Small Large

Patient details
*First name	*Last Name
*Address	*Suburb/City
*State	*Postcode
Email address	*Phone number
Is the condition short term or long term?*Short term (up to 6 months) Long term (longer than 6 months)	Does the patient receive funding?*NDIS Full funding Partial funding No funding Don't know
Please select the condition this patient hasSpinal Cord Injury Multiple Sclerosis Spina Bifida Other Urinary Issues Other Bowel Issues	Additional Information/Requests
	*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
*First name	*Last name
*Organisation	If other, please specify:	Address
Suburb/City	State	Postcode

*Send kit toPatient's Home Facility
Please invite this patient to join the Coloplast Care programYes
Please check the box to acknowledge that you have read and understood the Declaration of Consent.
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Headline

Continence Care Kit - samples to be sent to the patient

Intermittent Catheters

Urisheaths/Uridomes

Drainage Bags

Peristeen Anal Plugs

Patient details

Clinician details

Thank you for your order