Online Ordering

This page is currently only for use by people who are registered with a GP in Halton, St Helens, Wirral and Warrington CCGs. If you live in any other area please do not use this form. We will let you know when you are due to moved over to the MARSS service.

If you have previously ordered stoma supplies through your GP or a delivery company please use this form to place your order. If you are new to ordering stoma supplies please call us on 0800 915 9046 so we can set you up on our system.

If you have not yet had a welcome call from the MARSS service we will call you to discuss the service and confirm all your details on receipt of this form. Your prescription request will only be processed once we have spoken to you.

Title *

Mr
Miss
Mrs

First name: *

Last name: *

Date of birth: *//

Email address: *

Preferred contact number: *

Home address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

GP address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of hospital:

NHS Number

Have you had any stoma related problems since your last prescription *

yes
No

Have you had any sore skin since your last prescription *

yes
No

Have you needed to consult a healthcare professional about your stoma since your last prescription: *

yes
No

If you have answered yes to any of the above questions we will pass your details to our stoma nursing team for them to contact you:

I understand one of the MARSS nurses may contact me

Please indicate the codes of the products required below, along with the required quantities. For example 54101 – 1 box, 071-40 – 1 box, TR204 – 1 spray. Please also indicate which complimentary items you need, for example dry wipes, disposal bags.

Which dispenser would you like your prescription sending to?do (i.e. Coloplast Charter, Medilink, Bullens, local pharmacy):

Footer

Home
How the Service Works
FAQs & Useful Links
Online Ordering
Contact Us
Privacy Policy
Terms & Conditions

Site by

Home
How the Service Works
FAQs & Useful Links
Online Ordering
Contact Us
Privacy Policy
Terms & Conditions