Request Repeat Continence Products Online Form

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1. Request repeat continence products from the Community Equipment Store
  
  Use this form to request a repeat order of continence products, where an existing prescription is already in place. If you need to contact us, phone 01506280101 or email inco@westlothian.gov.uk
  
  This form should take less than five minutes to complete.
2. Full Name
3. Your address
  1. Your Address
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  4. Your Address
    
    OSG Postcode Search (Custom drop-down list)
    
    Postcode
    
    Address
4. Date of Birth
  
  Day
  
  Month
  
  Year
5. Phone Number
6. Email Address
7. Brief description of products required.
  If you know the product codes and/or names, please enter these.
8. If there is anything else we need to know, tell us below.