Community continence prescription form

What it contains

This form is used by community-based continence nurses to request continence equipment for Victorian WorkCover Authority (VWA) workers. The information in this form is for use by the VWA and will not otherwise be exchanged with any other party, except in accordance with law.

Please see section 8 of this form for privacy information.

• Please refer to the notes for assistance in completing this form
• All questions must be answered for this request to be considered by the VWA
• Please complete this form electronically, if able
• If you are unable to complete the form electronically, please use block letters when hand-writing
• Where there is insufficient space, please attach to the back of the form.