Order Form

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Order Form

Name:

Street:

City/State/ZIP:

Phone / E-mail:

Color	Qty	Style	Price per Pouch	Total
.	.	Complete Lacy Elegance	$13.00	_______
.	.	Top Lacy Elegance	$11.50	_______
.	.	Simple Pleasures	$11.00	_______
.	.	Whimsical	$11.00	_______
.	.	La Poche	$13.00	_______
.	.	Generic ABC	$12.50	_______
.	.	Feeding-Tube Pocket	$6.00	_______
For a correct fit, please send a pouch. The pouch will be returned with your order. Pouches will be made with an open bottom, a clip pocket, and an elastic flange unless requested otherwise. There will be an additional charge for custom design requests. Please e-mail prior to ordering for a price quote. Please allow up to 2 weeks for delivery.				Illinois Residents add 7.35% tax	_______
				S&H for 1-5 covers - or -	$2.50
				S&H for 6-10 covers	$4.50
				Total Enclosed	_______
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Pouch Pals--The highest quality, competively priced, custom-fit ostomy pouch covers that one can buy!