ORDER FORM for UNITED KINGDOM CITIZENS ONLY Name:(Mr/Mrs/Miss/etc.)..................................................Age:..... Address...................................................................................... ................................................................................................. Post Code................................Tel.No:......................................... Signature:........................................................Date:........................................ Please..... tick where applicable. Is this your first Sash belt, Yes......No....... Which of the sash belts do you wish to order? STOMA SUPPORT AND HERNIA.......... SECURITY AND LEAKAGE..........UMBILICAL HERNIA.......... Do you have a Colostomy.................Urostomy.................Ileostomy................... Stoma sited on your right hand side of the body.........or your left hand side of the body......... * Please enclose with this order form the following items or information: * A pouch you normally wear. If a 2-piece system, enclose both parts. * Waist size/belt length should be measured immediately above the hips, dipping down slightly around the stomach and over the stoma, see inset on "F.A.Questions" page. * Inches..................... cm`s.....................The Hernia belt will be supplied with a Velcro fastening and have approximately 2-3 inches (50-75mm) of adjustment. An NHS doctor’s prescription itemised:- *Sash Stoma Support and Hernia Belt, Drug Tariff reference number S1 *Security and Leakage Belt, Drug Tariff reference number SR103 If you prefer to purchase a sash belt, then please enclose a cheque made payable to SASH for the sum of:- *Stoma Support and Hernia Belt £40.92 *Security and leakage belts £28.02 Both the above prices are inclusive of post, packaging and VAT. Please post the above items (Order Form, Pouch, Prescription or cheque) to the address given below. Freephone - UK only - 0800 389 3111 Telephone or Fax. 01702 206 502 SASH Woodhouse Woodside Road Hockley Essex, SS5 4RU Last information update 01 January 2010