ORDER FORM for HERNIA or LEAKAGE BELTS
PLEASE NOTE WE DO NOT ACCEPT REQUESTS OR ORDERS FROM SUPPLY COMPANIES OR PHARMACIES 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.............................................................. Is this your first Sash belt, Yes...........No..........
Please tick 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..........
Please tick 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 1.5"-2" inches of adjustment.
* A UK NHS doctor’s prescription.
* To purchase a belt, we accept Sterling cheques made payable to SASH STOMA BELTS LIMITED or by bank transfer - Bank Account: Barclays - Bank Sort Code: 20-19-97 - Bank Account Number: 10316148
SWIFTBIC Code: BUKBGB22 IBAN Code: GB42 BUKB 2019 9710 3161 48
PLEASE NOTE THAT WE DO NOT ACCEPT CHEQUES FROM COUNTRIES OUTSIDE THE UK UNLESS STERLING £ CHEQUES
Sash Stoma Hernia Ostomy Belt HB102 costs £55.57 + VAT £11.11 = £66.68
Sash Security & Leakage Belt SR103 costs £26.18 + VAT £5.24 = £31.42
Shield SS104 costs £27.92 + VAT £5.58 = £33.50
Freephone - 0800 389 3111. (UK Only) Telephone or Fax. 01702 206 502
Email: sash.dennis@virgin.net
UK please use our Freepost address (do not write anything else on the envelope) :- FREEPOST SASH
Outside UK - Sash Stoma Belts 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 Stoma Belts Limited do not share personal information with any body other than patient's NHS GP Surgeries.