ORDER FORM

                                       for

                HERNIA or LEAKAGE BELTS

    

PLEASE NOTE WE DO NOT ACCEPT REQUESTS OR ORDERS FROM SUPPLY COMPANIES OR PHARMACIES FOR ANY OF OUR MADE TO MEASURE ITEMS.   PATIENTS MUST CONTACT US DIRECT IF THEY WISH US TO REQUEST A PRESCRIPTION FROM THEIR GP

 

 

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