Existing User

First name

Last name

Date of birth (e.g. 08/04/1979)

Email address

Preferred contact number

Home address

Has your GP surgery changed since the last order?

Yes

No

GP address

Please indicate the codes of the products required below, separated with a comma along with the required quantities. For example - 18201 - 5 packs of 10, 12035 -3 packs of 10, 12080 - 6 packs of 3

Your order will be fulfilled by your nominated delivery company. If you wish to nominate an alternative delivery company, please specify below.

If your order is dispensed by Coloplast Charter, please indicate any complimentary items you want to order:

Dry Wipes

Wet Wipes

Disposable Bags

Hand sanitizer gel

Is cutting required for your stoma bags?

Yes

Have you had any problems with your appliance, stoma or skin, since your last prescription was issued?

Yes

No

Do you need to speak to a Stoma or Continence Nurse?

Yes

No

Has it been over a year since a nurse reviewed your stoma or continence routine?

Yes

No

Additional notes

Welcome to Sefton Bladder and Bowel Prescription Service