Sto Med Inc.
Order Form

To place an order, print this order form, and mail it to:
Sto Med Inc.
P.O. Box 722005
San Diego, CA 92172-2005

or for immediate response, call 800-814-4195 for a Visa or MasterCard purchase.

• StomaGARDs                          $25.95 for 5
  HCPCS code #A5055
  Quantity:_____                                     Total:___________
  
  

• StomaGARD Kit                      $25.95 for 5 reusable strips
  HCPCS code #A5055
  Quantity:_______                                 Total:____________
  
  

• ShowerGARD                          $37.95 each
  HCPCS code#A5055
  Quantity:_____                                     Total:___________
  Waist Measurement (above the stoma): _____
  
  

• Plain ActiveGARD                    $37.95 each
  HCPCS code #A9270
  Quantity:_____                                     Total:__________
  Waist measurement AT the stoma:_____
  
  

• Lace ActiveGARD                    $44.95 each
  HCPCS code #A9270
  Quantity:_____                                     Total:__________
  Waist measurement AT the stoma:_____
  
  

• SportGARD                             $57.95 each
  HCPCS code # A5055
  Quantity:____                               Total:  _________
  Waist measurement AT the stoma:_______
  
  

• SwimGARD                             $37.95 each
  Quantity:________                         Total:________
  Waist measurement at the stoma:______
  
  

• HerniaGARD                           $57.95 each
  Quantity:_____                             Total:__________
  Waist measurement AT the stoma:______
  
  

All non-disposable products have a six month warranty on material and workmanship.  Sto Med Inc. disclaims the ability of any of the products to protect any area from harm that results from unreasonable force.  The company does not by implication or other statements imply any responsibility for harm caused while using the above named products.  These products are not intended for anything other than comfort.

Shipping and Handling:   $4.00__________

Total__________

Personal Check             Visa                 MasterCard Remember to include your waist measurement!

Card Number:_________________________________

Expiration Date:_______________________________

Name:_______________________________________

Address:_____________________________________

City:____________  State:____Zip Code____________

Phone Number: _______________________________

Mail or call your order in to:
Sto Med Inc.
P.O. Box 722005
San Diego, CA 92172-2005
800-814-4195