Take Wellness Assessment

Reorder Ostomy Supplies

Please fill out the form below to reorder your Ostomy Supplies.

  • First Name:*
  • Last Name:*
  • Email:*
  • Phone Number:*
  • Account Number:

  • How many times per day do you dispose of your ostomy supplies on average?

  • Please select the following supplies you would like to order. You are only eligible to refill these items if you have less than 14 days on hand.
  • Does your ostomy belt no longer function due to wear and tear or damage?

  • If any items such as Shipping Address, Phone, Physician, or Insurance has changed, please tell us what has changed and add the new information below:

  • My name is My relationship to the patient is: and I give consent authorizing Med-Care Diabetic & Medical Supplies to send the next shipment.