ORDER FORM

                                       for

                HERNIA or LEAKAGE BELTS

    

 

 

 

 

 

Name:(Mr/Mrs/Miss/etc.)...........................................................................               Date of Birth............

 

Address..................................................................................................................

 

Post Code.........................Country.........................................        Tel.No:........................................................

 

 Please tick where applicable.      Is this your first Sash belt, Yes......No......  Which Sash Belt do you wish to order?

 

STOMA HERNIA (HB102) ........ SECURITY & LEAKAGE (SR103)..........UMBILICAL HERNIA (HB102)..........

 

Do you have a Colostomy.................Urostomy.................Ileostomy..................Umbilical Hearnia....................

 

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 3 inches (75mm) of adjustment.

 

*   A UK NHS doctor’s prescription.

If you wish to purchase one of our belts please send a cheque with your order made out to SASH MEDICAL LTD.  Or by BACS to:-   Barclays Bank,   Sort Code 207093,   Account No.70702153

 

NOW TAKING CARD PAYMENTS OVER THE PHONE PLEASE CALL US TO MAKE A DIRECT PAYMENT

 

Sash Stoma Hernia Ostomy Belt HB102 costs £63.78.       Or the equivalent in your local  currency, (Cheques only)

Sash Security & Leakage Belt SR103 costs £30.05             Shield SS104 costs £32.05

 

Freephone - 0800 389 3111. (UK Only)

Telephone or Fax. 01702 206 502

email.  sash.dennis@virgin.net

 

Freepost RTJE-CTGZ-HBTT (UK Only)

SASH

Woodhouse

Woodside Road

Hockley Essex  SS5 4RU  England