CUSTOM MEASURED GARMENTS 12-111 Fourth Ave., Suite 347, St. Catharines, ON L2R 1Y7 T: 1-855-857-8500 F: 1-855-857-8570 E: Orders@LymphedemaDepot.com Visit us online at: www.LymphedemaDepot.com SHIPPING INFORMATION Ship To: BILLING INFORMATION Attn: Street: Bill To: Attn: City: Street: Province: CONTACT INFORMATION Postal Code: Province: Name P.O. # Pay By: Postal Code: V.160705- EFFECTIVE JULY 5, 2016 City: On Account Visa MasterCard Cheque Enclosed Phone: Fax: CC # Request Call for CC# ? : Exp: Email: 2015 PROFESSIONAL MEASURING AND ORDER FORM PLEASE MEASURE IN CENTIMETRES. USE COMMENTS FOR SPECIAL INSTRUCTIONS. Client Name (for warranty): ORDER DETAILS: QTY BLACK Toe Unit(s), (Left Right ) Custom Standard Please Advise Foot Unit(s), (Left Right ) Custom Standard Please Advise Calf Piece(s) Custom Standard Please Advise Knee Piece(s) Custom Standard Please Advise Thigh Piece(s) Custom Standard Please Advise Extension(s), Single Extension(s), 6-Pack QTY BEIGE UNIT PRICE Extension straps are sold singly or in 6-packs. Extensions are designed to attach with Velcro and add 10 cm of length to any ReadyWrap Calf, Knee or Thigh strap. ExoFusion Sock Liners Toes-to-Knee Liner with 20-30mmHg in foot and ankle only. Sold in pairs. Black Only. Circle Size: Short Medium Tall Medium Short Large Tall Large. Silver Liners, Knee High Length 60 cm ; Fits Circumferences up to 60 cm ; Sold in Pairs Silver Liners, Thigh High Reg Length 95 cm ; Fits Circumferences 48-74 cm ; Sold in Pairs Silver Liners, Thigh High Max Length 95 cm ; Fits Circumferences 74-103 cm ; Sold in Pairs Terms and Conditions: We extend Net-30 terms to established accounts; contact us for a Credit Application. All other orders must be prepaid by Visa, MasterCard, Interac eTransfer, PayPal or cleared cheque. Flat rate shipping charge of $10 for delivery within Canada. There may be a small surcharge for delivery to residential addresses. Standard garments delivered in 1-6 business days, depending on the destination of your order. Custom work add 1 week. Alternate or rush shipping methods and/or priority production of custom garments may be available by request; please call to discuss. Returns and Cancellations: All medical garment sales are final. Lymphedema Depot is proud to provide quality products and excellent customer service; we are always happy to work with our customers to resolve any issue with your order. Kindly inspect your order promptly upon receipt. A discrepancy, sizing adjustment or product found defective at time of sale may be returned for exchange within 7 days of receipt with a pre-authorization. Custom-manufactured garments cannot be cancelled, returned, exchanged or refunded once production has begun. Returned merchandise will only be accepted when received in unworn, unlaundered condition in its original, undamaged packaging. Orders cancelled after shipment will incur round-trip freight charges. Shipping & handling is non-refundable. Prices are subject to change without prior notification. All prices are in Canadian dollars and subject to applicable Canadian sales taxes (Reg. #83343 7221 RT0001). **ReadyWrap is not subject to GST/HST when prescribed by a physician** Sub-total : S&H : Taxes : Total : LINE TOTAL