ORDER FOR SUPPLIES

ORDER FOR SUPPLIES

Orders may be placed at any point during the month the supplies are required, up until the 25th. Orders will be processed as received and in the month the supply is for. Orders will be dispatched within 10 working days. Orders placed after the 25th will be automatically be moved to the following month. Please ensure that the product codes entered are correct, as goods are supplied in accordance with this code and cannot be exchanged. Orders cannot be altered once submitted.
Name *

First Name Middle Initial Last Name
Name must match what is printed on your Medicare Card
Medicare Number *
Line Number *
Expiry Date *
Address *

Street Address

Street Address Line 2

City State

Post Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Order Option *

COLLECTION (not currently available) SEND
Delivery Preference *

LEAVE MY PACKAGE SIGNATURE REQUIRED
Ship to Address above? *

Yes No
Shipping Address *

Street Address

Street Address Line 2

City State

Post Code
Order for the month of: *
Example: December 2021
Is this a two month order? *

Yes No

Supplies

*Product code(s) are found on the outside of the box that contains your supplies
Mail deliveries: Shipping is $15.00 for a single month order and $20.00 for a two-month order (GST Included).
Payment Method *
Cheques/Money Orders:
Please make Cheques/Money Orders payable to ACT & Districts Stoma Association Inc.

Postal Address
GPO Box 1260, Canberra City ACT 2601
Phone: (02) 51244888
Email: stoma@actstoma.onmicrosoft.com
www.actstoma.net.au
Direct Credit:
Commonwealth Bank
Account Name: ACT & Districts Stoma
Association
BSB: 062 919 A/C: 00910631
Ref: PLEASE INCLUDE YOUR NAME
My Products
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Shipping $ 15.00 AUD
For a single month order.

Two Month Order $ 5.00 AUD
Additional Charge. Please select if your order is for two months.

Total $ 0.00 AUD
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