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 _______

.

.

Openings For Belt

$2.00 _______
For a correct fit, please send a pouch.  The pouch will be returned with your order or enclose the name of the manufacturer & reorder number of your pouch. 

Pouches will be made with an open bottom, a clip pocket, and an elastic flange unless it is La Poche pouch or is requested otherwise.

Please allow up to 2 weeks for delivery.

Illinois Residents add 7.85% tax

_______

S&H for 1-5 covers  - or -

$3.50

S&H for 6-10 covers

$5.50

Total Enclosed

_______

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