New User

Title

First name

Last name

Date of birth (e.g. 08/04/1974)

Email address

Preferred contact number

Home address

GP address

Name of Hospital

Name of your Nurse

NHS Number

Operation date

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 Coloplast Charter, 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 would like to order:

Complimentary Coloplast Charter Dry Wipes

Complimentary Coloplast Charter Wipes

Complimentary Coloplast Charter Disposal Bags

Complimentary Isagel

Cutting required

Is this your first order?

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

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

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

Additional notes

Welcome to Sefton Bladder and Bowel Prescription Service