Title
 Mr Mrs Miss Ms

Initials:
First Name: Surname: Date:
Street: Suburb: Postcode:
Phone: Mobile: Email:
Membership No.
Brand Product Code Description QTY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Note: To obtain more than the monthly allowance, an Extra Supply Form signed by a Stomal Therapy Nurse or Doctor must be produced before the extra supply will be issued.

Delivery Method

By POST:
 Melbourne Suburbs ($10) Victorian Country ($12) Interstate ($14) -- OR --
 PICK UP

Double Orders (ie. 2 months’ supply)
Please include DOUBLE THE POSTAGE FEE
(Always allow time for your items to be ordered and despatched - this can be up to 14 days)

Preferred Payment Method

 Direct Deposit Cash Credit Card Cheque Money Order

Cheques and Money Orders made payable to
ILEOSTOMY ASSOCIATION (VIC) INC.

Mailing Address:
PO BOX 32,
Flinders Lane, 8009
Direct Deposit Info:
Commonwealth Bank
Account Name: Ileostomy Association (Vic) Inc.
BSB: 063 010
Account No.: 11382779
Amount Paid:
Date Paid:

Please note: Please identify your payment with your name or membership number and a word describing the payment ie. Fees
Paying by Credit Card:
We cannot currently process credit card payments through the website. If you would like to pay via credit card, please call us on

(03) 9650 9040 (during office open hours)