Order Online Member's Detail Surname Given Name Address Suburb PostCode This order was placed by: Print Name Email —Please choose an option—Geelong Ostomy IncBendigo & District Ostomy Association IncCancer Council of NT IncColostomy Association of NSW IncColostomy Association of SA IncColostomy Association of VIC IncGold Coast Ostomy Association Inclleostomy Association of NSW LTDlleostomy Association of SA Inclleostomy Association ofVIC IncNorth Queensland Ostomy Association IncOstomy Association Of Melbourne IncOstomy Tasmania IncQLD Ostomy Association IncQLD Stoma Association IncToowoomba & South West Ostomy Association IncVictorian Children's Ostomy AssociationWarrnambool & District Ostomy Association IncWide Bay Ostomates Association Inc Member of Distribution Directions: —Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Month —Please choose an option—20242025202620272028 Year —Please choose an option—Collect from 6 Lewalan Street GrovedalePOST $15 nominal charge per month supplyVeteran Affairs POST Delivery Option Please Note : Postage must be pre-paid before order is shipped. Contact Geelong Ostomy for latest schedule of postal charges. Please Note Collection is available only after the 5th of the Month of distribution on:Monday, Wednesday, Friday 9.30 am to 2.30 pm. Medicare Card details are no longer required with each online order. Please advise details of new Medicare Card issue and it's expiry date. Med Cert(if have one) —Please choose an option—3MAinscorp (Salts)B.BraunConvatecColoplastDansacHollisterOmnigon ( Welland, Eakin)McFarlaneStatinaSutherland MedicalBrand Product Code Amount Yes Med Cert(if have one) —Please choose an option—3MAinscorp (Salts)B.BraunConvatecColoplastDansacHollisterOmnigon (Welland, Eakin)McFarlaneStatinaSutherland MedicalBrand Product Code Amount Yes Med Cert(if have one) —Please choose an option—3MAinscorp (Salts)B.BraunConvatecColoplastDansacHollisterOmnigon (Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—3MAinscorp (Salts)B.BraunConvatecColoplastDansacHollisterOmnigon (Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—3MAinscorp (Salts)B.BraunConvatecColoplastDansacHollisterOmnigon (Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—3MAinscorp (Salts)B.BraunConvatecColoplastDansacHollisterOmnigon (Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—3MAinscorp (Salts)B.BraunConvatecColoplastDansacHollisterOmnigon (Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) Orders This order form must be submitted BEFORE 2:30pm on the 18th of the month prior to the required month of distribution (eg 18 Jan for Feb order). Be aware of holidays and place your orders early. Late orders or late order changes may incur additional fees, members will be informed prior to order being processed. Orders will be available for pick-up at 6 Lewalan Street, Grovedale, any Monday, Wednesday or Friday’s after the 5th of the month of distribution between the hours of 9:30am to 2:30pm only. Special Instructions or Messages
