sample order form electronic - iarap.com.au order form electronic.pdf · type: male female brand:...
TRANSCRIPT
Please tick the box of the size required. A maximum of three Pad Types can be ordered. Two pads will be issued per Pad Type. To place your order please send this form to the Independence Australia Customer Service team via fax 1300 788 811 or email [email protected].
Referral Details
Full Name:
Employer:
Last First
Phone: (
)
E-mail Address:
Customer Details
Full Name:
Last First
Address:
House/Unit No. Street
City State Postcode
Phone: (
)
E-mail Address:
Guards & Shields
Absorption requirement: Low Moderate High
Type: Male Female
Brand:
Brand:
No Preference Booster Pads
Absorption requirement: Low Moderate High
Brand:
Brand:
No Preference Belted All In One (Nappy Style)
Absorption requirement: Low Moderate High Waist measurement:
Size requirement: Sml Med Lge Xlge
Brand:
Brand:
No Preference Pull Ups
Absorption requirement: Low Moderate High Waist measurement:
Size requirement: Xs Sml Med Lge Xlge
Brand:
Brand:
No Preference Stretch Pants
Size requirement: Sml Med Lge Xlge Waist measurement:
Brand:
Brand:
No Preference
T 1300 788 855 | F 1300 788 811 | E [email protected] | W www.indepedenceaustralia.com
Disposable Pad Sample Order Form