Queensland Stoma Association Inc

Unit 1, 10 Valente Close, Chermside 4032 Post Office Box 370, Chermside South 4032 Website: www.qldstoma.asn.au Email: [email protected] Telephone: (07) 3359 7570 Facsimile: (07) 3350 1882 ORDER FORM (please print clearly)

SURNAME:- GIVEN NAMES:- APPLIANCE ENTITLEMENT ADDRESS:- CARD NO

SUBURB:- POSTCODE:-

PLEASE INDICATE IF ADDRESS HAS CHANGED SINCE LAST ORDER

TELEPHONE NO:- EMAIL:-

OFFICE ITEM OR DESCRIPTION:- QTY IN # PACKS PRODUCT CODE* BRAND USE Bag, Pouch, Wafer, Flange, etc. PACK ORDERED ONLY

PURCHASED ITEMS

*Members must ensure that the product code quoted is correct as goods will be supplied in accordance with this code. Goods will only be supplied within Stoma Appliance Scheme guidelines. QSA recommends that the advice of an STN or medical practitioner be sought before using products which have not previously been used. Information provided by QSA about the availability and/or features of any product is not intended to be an advice or recommendation as to the suitability of that product for use. I will be picking up this order on  or after / / Month to be P/P/H Fee paid by OFFICE USE ONLY  posted cash/chq/credit: ORDER RECEIVED _____/_____/____ $ 10 for 1 month standard supply / $15 for up to 2 month supply P.P.H FEE ______sent as one parcel. (These charges apply to standard orders. Large parcels may incur a ORDER surcharge to cover extra cost of postage) COMPLETED _____ / _____ / _____ I am a holder of Department of Veterans Affairs Gold Card

I confirm that all products provided to me through the Stoma Appliance Scheme are for my own personal use. ENTERED FOR MONTH ______SIGNATURE:

Please debit my MasterCard/Visa card Name on Card: Card Number: E Expiry: / Plus 2% credit card fee for Amount: $ (month) Cardholders Signature: