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).........
IF SHIELD TO BE ATTACHED TO HERNIA BELT PLEASE TICK WHICH TYPE: 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. We do not accept cheques from The Philipines or Republic of Ireland
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 UK only post to:- FREEPOST SASH MEDICAL LTD
Outside UK - Sash Medical Ltd, Woodhouse, Woodside Road, HOCKLEY, Essex, SS5 4RU England
GDPR - "Consent of the data subject means any freely given, specific, informed and unambigiguous indication of the data subjecy's wishes by which he or she, by a statement or a clear affirmatio action, signifies agreement to the processing of personal data relating to him or her." Sash Medical Ltd do not share personal information with any body other than patient's NHS GP Surgeries.