Order By Mail
Use this form to place orders on any of the products listed in our "Store" page of our web site.
Please complete the form with your information and the products quantity you want to order.
Note: Please list a company name if this is a business purchase, as well as a street address for shipping purposes. Your personal or business information will be used for internal use only and will not be shared with other organizations or individuals.
Person Ordering
*Full Name:
*Phone # + Ext:.
*Email Address:
Shipping Address
NOTE: No post office boxes please
*Company Name:
*Address Line 1:
Address Line 2:
*City, State, Zip:
Select the sizes and quantities of each item:
NOTE: All prices in Canadian $
Item Description Price Quatity
Short Sleeve Jackets
Short Sleeve Jackets 		Medium Women's Size $  425.00
Small Women's Size $  350.00
Small Men's Size $  425.00
Large Men's Size $  575.00
Medium Men's Size $  500.00
Large Women's Size $  500.00
Long Sleeve Jackets
Long Sleeve Jackets 		Large Women's Size $  600.00
Medium Women's Size $  550.00
Small Women's Size $  500.00
Large Men's Size $  735.00
Medium Men's Size $  655.00
Small Men's Size $  575.00
Knee/Elbow Wrap
Knee/Elbow Wrap 		L -- #520 $  160.00
M -- #510 $  140.00
S -- #500 $  120.00
Lower Back Belts
Lower Back Belts 		XS - #390 $  135.00
S --- #391 $  150.00
M --- #392 $  165.00
L --- #393 $  185.00
XL -- #394 $  195.00
XXL - #395 $  215.00
Thigh Wrap
Thigh Wrap 		Large $  155.00
Medium $  145.00
Small $  135.00
Wraps and Blankets 10% DISCOUNTED UNTIL FEBRUARY 29 2012
Wraps and Blankets 10% DISCOUNTED UNTIL FEBRUARY 29 2012 		B - #110 $  76.50
A - #105 $  67.50
D - #120 $  153.00
E - #125 $  247.50
C - #115 $  144.00
G - #130 $  405.00
H - #135 $  472.50
J - #140 $  603.00
Faraband Wraps
Faraband Wraps 		A - #600 $  30.00
B - #605 $  65.00
Amputee Limb Covers
Amputee Limb Covers 		XXL - #235 $  215.00
S ---- #215 $  140.00
L ---- #225 $  170.00
XXS - #205 $  130.00
M --- #220 $  150.00
XL --- #230 $  190.00
XS -- #210 $  130.00
* Required Fields