Stoma Appliance Scheme application form (PB049)

Use this form to show your eligibility to receive products under the Stoma Appliance Scheme.

Both the applicant and the referring medical practitioner or stoma therapy nurse must complete this form.

You must complete a separate form for each stoma.

This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, there are other ways you can do your business with us. You can use self service or request someone to deal with us on your behalf. If you can’t access our forms, please contact us. We can help you access, complete and submit them.

Page last updated: 14 March 2019

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