Online Ordering

If you have previously ordered stoma supplies through your GP or a delivery company please use this form to place your order. If you are new to ordering stoma supplies please call us on 0808 141 0824 so we can set you up on our system.

First name: *

Last name: *

Date of birth: *

Email address: *

Preferred contact number: *

Home address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

GP address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of hospital:

NHS Number

Have you had any stoma related problems since your last prescription *

Have you had any sore skin since your last prescription *

Have you needed to consult a healthcare professional about your stoma since your last prescription: *

If you have answered yes to any of the above questions we will pass your details to your stoma nursing team for them to contact you:

I understand one of the nurses may contact me

Please indicate the codes of the products required below, along with the required quantities. For example 54101 – 1 box, 071-40 – 1 box, TR204 – 1 spray. Please also indicate which complimentary items you need, for example dry wipes, disposal bags.

Which dispenser would you like your prescription sending to do? (i.e. Coloplast Charter, Medilink, Bullens, local pharmacy):

Online Ordering

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