Order Form

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Order Form

Name:

Street:

City/State:

Zip Code

Phone or E-mail:

Color	Qty	Style	Price per Pouch	Total
.	.	Complete Lacy Elegance	$10.50	_______
.	.	Top Lacy Elegance	$9.00	_______
.	.	Simple Pleasures	$8.50	_______
.	.	Whimsical	$8.50	_______
.	.	La Poche	$10.50	_______
.	.	Generic ABC	$10.00	_______
.	.	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.				Illinois Residents add 7.1% tax	_______
				S&H for 1-5 covers - or -	$2.00
				S&H for 6-10 covers	$4.00
				Total Enclosed	_______
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Pouch Pals--The highest quality, competively priced, custom-fit ostomy pouch covers that one can buy!