Useful Forms

Members Forms

Monthly Appliance Order Form

Orders for the current month must be received by the second last business day of that month

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REGISTERED STOMAL THERAPY NURSE FORMS

The below forms are strictly for use by a Registered Stomal Therapy Nurse ONLY! Members are not permitted to submit these forms. Member who submit any of the below forms will have their order cancelled and will need to resubmit their order again with the correct form.

PBS Stoma Appliance Scheme Application Form

To be completed by Medical Officers and Stomal Therapy Nurses

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SAS Application for Additional Stoma Supplies

To be completed by Medical Officers and Stomal Therapy Nurses

Download PDF

Irrigation Kit Authorisation Form

To be completed by Medical Officers and Stomal Therapy Nurses

Download PDF
Tieman Tip Catheters Authorisation Form

To be completed by Medical Officers and Stomal Therapy Nurses

Download PDF

Deodorant and Absorption Gelling Sachets Authorisation Form

To be completed by Medical Officers and Stomal Therapy Nurses

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Stoma Appliance Scheme – Cleanser wipe authorisation form

To be completed by Medical Officers and Stomal Therapy Nurses

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Stoma Appliance Scheme – Peristeen Plus authorisation form

Use this form to apply for access to Peristeen Plus on the Stoma Appliance Scheme. This form should be completed by the applicant or their authorised representative as well as the applicant’s authorised health professional.

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Stoma Appliance Scheme – Application form for additional supplies – Travel or remote location

Use this form to apply for additional supplies under the Stoma Appliance Scheme (SAS) for more than 2 months’ supply and up to 6 months’ supply, if you are:

  • travelling outside Australia, or
  • living remotely (including Norfolk Island residents).

Download PDF

Orders may be submitted by email to [email protected] using the order form linked above.
Please include your membership number, name, address, item numbers and quantities of the products you require and indicate if the order is to be shipped or collected from the distribution centre.

Alternatively the orders can be posted to

Postal Address: PO Box 79 Torrensville Plaza SA 5031

Please allow 14 days for processing and delivery.

Instructions On PDF Forms

You may complete these forms either digitally or manually.

Once the PDF form(s) has been completed you can return back to us via:

  • Email: [email protected]
  • Post: PO Box 79 Torrensville Plaza SA 5031
  • Fax: (08) 8234 2985