Fax Order Form
Print out this form, complete and fax it to:
Fax Number: (805) 389-8142
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Your Name: |
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| Address: | |
| City, State, Zip | |
| Phone: | |
| Birth date: | |
| Insurance Information: |
| Quantity | Description | Price |
| GeeWhiz IMD Monthly Pack (29mm, 32mm, 36mm) | See Shopping Cart | |
| GeeWhiz IMD Accessories (Leg Bag, Bed Bag, Tubing, Adaptors) | See Shopping Cart | |
| Starter Packs for Known and Unknown sizes | See Shopping Cart | |
| ASK ABOUT INSURANCE COVERAGE |
ABSOLUTELY NO RETURNS ON MEDICAL ITEMS