Fax Order Form
Print out this form on your printer,
fill it out and fax it to:
Fax Number: (805) 389-8142
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| 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. | $99.00 Plus $7.50 Shipping & Handling |
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