Skip to content
Call Us
Home
Ordering
Online Nurse Referral
Direct Patient Referral
About
Our Story
Our Team
Help
Contact Us
FAQ
Menu
Home
Ordering
Online Nurse Referral
Direct Patient Referral
About
Our Story
Our Team
Help
Contact Us
FAQ
Call Us
Direct Patient Referral Form
Please fill out the form below and click send
Are you ordering for yourself?
Yes (Move to the next step)
No (Enter Nurse details below)
Nurse Name
Nurse Contact Number
Nurse Email Address
Hospital Name
First Name
Second Name
Date of Birth
NHS Number
Mobile Number
Landline Number
Email Address
Type of Dialysis
PD
HD
House Name or Number
Line 1
Line 2
Town or City
Post Code
Delivery Details
GP Surgery Name
City/Town
Postcode
Prescription Charge Exemption Status
Exempt
Not Exempt
Unknown
VAP1 - Medium Pouch - PK 10
View
0
1
2
3
4
5
6
7
8
9
10
VAP2 - Large Pouch - PK 10
View
0
1
2
3
4
5
6
7
8
9
10
VAP3 - Small Pouch - PK 10
View
0
1
2
3
4
5
6
7
8
9
10
ND- 0001 - PK 30
View
0
1
2
3
4
5
6
7
8
9
10
EA2 - Extra Sticky Pouch - PK 10
View
0
1
2
3
4
5
6
7
8
9
10
BW2 - Fusion Applicator 3ml - PK 5
View
0
1
2
3
4
5
6
7
8
9
10
BW3 - Fusion Applicator 1ml - PK 5
View
0
1
2
3
4
5
6
7
8
9
10
SB2 - Acubond Strips - PK 5
View
0
1
2
3
4
5
6
7
8
9
10
3505 - Medical adhesive remover wipes - PK 30
View
0
1
2
3
4
5
6
7
8
9
10
3820 - Barrier wipes - PK 30
View
0
1
2
3
4
5
6
7
8
9
10
RS1 - Remover Spray 50ml
View
0
1
2
3
4
5
6
7
8
9
10
BW1 - Barrier Wipes - PK 30
View
0
1
2
3
4
5
6
7
8
9
10
ARW1 - Adhesive Remover Wipes - PK 30
View
0
1
2
3
4
5
6
7
8
9
10
Special Instructions
Do you want this to be an automatic monthly order?
Yes
No
(If yes) how should we coordinate?
Not applicable
Text
Call
Email
Send
