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)





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
Support Services declaration of consent


Free sample - Free shipping

Thank you for your order


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