PO BOX 198 MOOROOKA Q 4105 E-mail: admin@qldostomy.org.au Phone: (07) 3848-7178 Fax: (07)3848-0561 Web: www.qldostomy.org.au Orders for the Month of* Appliance Entitlement Card Number* Post / Pickup / VA* Full Name* Email** Email Address* Phone* Orders to be in early as possible in the PRECEDING Month Brand Item Code No. on the Box Quantity Req'd