Name:________________________________________________ Address:______________________________________________ (street address needed for UPS delivery!) _____________________________________________________ _____________________________________________________ Telephone:____________________________________________ PRODUCT(S) TO BE ORDERED: Product(s):____________________________________ ______________________________________________ CIRCLE ONE: 1/ 1-piece . . or . . 2-piece system 2/ Closed pouch . . or . . Drainable pouch 3/ Clear film . . or . . Opaque film 4/ Stoma size: . . . cut-to-fit . . . 3/4 inch . . . 7/8 inch* . . . 1 inch . . . . 1 1/4 (1 3/16) inch . . . . 1 3/8 inch . . . . 1 1/2 inch . . . . 1 3/4 inch . . . . 2 inch . . . . 2 3/8 inch 5/ If 2-piece: Ring 35 . . . . Ring 50 . . . . Ring 65 . . . . Ring 80 Quantity:_______________________________________ Price:_________________________________________ A $5.- handling fee will be added to any order under $100.-Preferred shipping method: ________________________ Remarks:______________________________________ ______________________________________________ Payment by (please circle one): . . . Money Order . . . COD Credit card: . . . VISA . . . . Mastercard Cardnumber:___________________________________ Expiration Date:________________________________ Signature: ____________________________________ Print name (as it appears on card): ______________________________________________ |