Stoma Appliance Scheme application form (PB049)

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

Download and complete the Stoma Appliance Scheme application form.

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.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 3 March 2022