Fax Order Form
Print out this form on your printer, fill it out and fax it to:
Fax Number: (805) 389-8142
|
Your Name: |
|
| Address: | |
| City, State, Zip | |
| Phone: | |
| Birth date: | |
| Insurance Information: |
| Quantity | Description | Price |
| Starter Pack includes: 35 sheaths, 35 Patented Secure "Gel", Strips & Secure Strips, Extension Tubing, Leg Bag and/or Bedside Drain Bag, full instruction book. | See Shopping Cart | |
| Starter Pack Includes: 35 sheaths, 35 Patented Secure "Gel" Strips, & Secure Strips, Integral Collection Pouch, Extension tubing, Leg Bag and/or Bedside Drain Bag, Full instruction book. | See Shopping Cart | |
| Starter Packs for known and unknown sizes | See Shopping Cart | |
| ASK ABOUT INSURANCE COVERAGE |