FLUSHABLE LINERS ORDER FORM
(PLEASE PRINT
THIS PAGE TO SEND WITH YOUR ORDER, OR
When e-mailing your request, please use OSTOMY LINERS as your subject and send
your mailing address)
NAME: PHONE: ( )
ADDRESS:
CITY: STATE: ZIP CODE:
FAX: ( ) E-MAIL ADDRESS (if available):
PLEASE SEND ME:
ONE BOX OF 300 LINERS $ 64.00
SHIPPING AND HANDLING $ 7.95
TOTAL $ 71.95
METHOD OF PAYMENT: Check or money order enclosed Master Card Visa
NAME ON CARD:
CARDHOLDER SIGNATURE:
CARD #: EXPIRATION DATE:
For each question, CIRCLE "Y" for YES
and "N" for NO.
Do you have: A colostomy? Y / N An ileostomy? Y / N A septic system? Y / N
Will
you have a reversal? Y / N
Your pouch size:
Did an ET Nurse
refer you?
Y /
N IF
YES, PLEASE COMPLETE THE FOLLOWING:
NAME: PHONE: ( )
HOSPITAL:
ADDRESS:
CITY: STATE: ZIP CODE:
FAX: ( ) E-MAIL ADDRESS (if available):
........................................................................cut here.............................................................................
FREE SAMPLES
Please send me 2 free flushable ostomy liners to try.
NAME: PHONE: ( )
ADDRESS:
CITY: STATE: ZIP CODE:
FAX: ( ) E-MAIL:
Theresa A. Conti, MPS
3215 Imperial
919-562-5480
e-mail: tacliners@yahoo.com
www.flushableostomyliners.com
When e-mailing your request, please use OSTOMY LINERS as your subject and send your mailing address.