Qufora Ordering and Support

We’re ready to get your patient started. By completing this form, you are confirming that your patient wishes to receive myqufora support for ongoing guidance adopting their product, following your teaching on how to use it.

To help us support your patient safely and effectively, please complete all fields. Your patient will automatically be registered to receive their product from Qufora Direct.

Patient NHS Number

Does your Patient pay for their prescriptions?

Title

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Patient's Preferred Contact Number

Patient's Alternative Contact Number

Patient's Email Address

Patient's Address

Address Line 1

Address Line 2

City

Post Code

GP Details

GP Practice Name

GP Name

Gp Contact Number

GP Address

Address Line 1

Address Line 2

City

Post Code

Any other comments/Delivery information?

Patient Condition

Product Choice

Please select the products below that you wish to prescribe to your patient.

requires product urgently

If your patient does NOT require product urgently, please select this box

opt out of auto delivery

If your patient does NOT wish to be enrolled in our automated delivery service, please tick this box

opt out of myq support

If your patient does NOT require support from the myqufora team, please tick this box.

My Irrigation Booklet

Have you given your patient a My Irrigation Booklet?

Healthcare Professional Details

Healthcare Professional Name

Healthcare Professional Contact number

Healthcare Professional Department

Healthcare Professional Address

Address Line 1

Address Line 2

City

Post Code

Healthcare Professional Email

Please enter your E-Mail address so we can send you a confirmation email.

Visit your local country site

Denmark

Professionelt brug

Personligt brug

Germany

Professionelt brug

Personligt brug

Italy

Professionelt brug

Personligt brug

Netherlands

Professionelt brug

Personligt brug

Professional use

Personal use

Other countries

Corporate

Important notice

The content is for informational and educational purposes and is not intended for other audiences. Qufora does not provide medical advice, and responsibility for patient care lies with the individual HCP. Detailed information about the presented products, including instructions for use (IFU), contraindications, precautions, and warnings, can be found in the product documentation before use.

Qufora Ordering and Support

GP Details

Patient Condition

Product Choice

Qufora IrriSedo MiniGo

Qufora IrriSedo MiniGo Flex

Qufora IrriSedo Klick

Qufora IrriSedo Flow

Qufora IrriSedo Bed

My Irrigation Booklet

Healthcare Professional Details