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.).....................................................................................................................................
Address.................................................................................................................................................................
Post Code.............................Country......................................... Tel.No:........................................................
Date of Birth.....................................
Please tick where applicable. Is this your first Sash belt, Yes......No......
STOMA HERNIA (HB102) ........ SECURITY & LEAKAGE (SR103)........UMBILICAL HERNIA (HB102).........
ATTACHED SHIELD ON STOMA HERNIA (SS104 & HB102) ........ HIGH PROFILE....... LOW PROFILE.....
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 around the stomach and over the stoma.
* 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 pay by BACS to:- Barclays Bank, Sort Code 207093, Account No.70702153
For BACS International customers SWIFTBIC - BUKBGB22 IBAN - GB39 BUKB 2070 9370 7021 53
Barclays Bank 63-65 High Street, Rayleigh, Essex SS6 7EL
We are sorry but we can not accept cheques from The Philipines or Republic of Ireland due to bank charges
Sash Stoma Hernia Ostomy Belt HB102 costs £64.27
Sash Security & Leakage Belt SR103 costs £30.29
Shield SS104 costs £32.30
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 UK