The following form is to be downloaded and filled in by:

  • Applicants to receive products under the Stoma Appliance Scheme (PART 1)
  • Referring medical practitioner or stomal therapy nurse (PART 2)

Download the Stoma Appliance Scheme Application here (pdf 112kb)

Once filled in, please return your form to:

ILEOSTOMY ASSOCIATION (VIC) INC.
Postal Address: PO Box 32 Flinders Lane VIC 8009