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P.O.Box 10
Haines Falls, NY 12436

TOLL FREE: 1-888-843-3334
TELEPHONE: 518-589-6331
FAX: 518-589-6332

ORDER FORM



Purchase Order#   
Name              
Company Name      
Street address    
City              
State/Province    
Country           
Zip/Postal code   
E-mail address    
Phone             
Fax

Comments or ship to address (if different from above)

Quantity	Product Code	Product Description	Unit Price	Total $
	10001	THE ASTA-CATH FEMALE CATHETER GUIDE**	$48.00
	20001	THE FEMINAL FEMALE URINAL	$14.99*
			Subtotal
		Shipping & Handling (Continental US only) $6.00 for 1-3 items, $2.00 for each additional item.

			Total

**A prescription is required for this product. Name of medical professional who will be faxing or mailing prescription: Name:
Telephone:

Medicare Reimbursement Code (HPCPCS):
FEMINAL - E0326

PAYMENT METHOD
Facility Please bill us Individual I will be sending a check, or,
To Order by Credit Card, please
call toll free 1-888-843-3334

*FACILITY PRICING

THE FEMINAL: $10.50 each
Case of 12: $9.00 each
Case of 50: $7.50 each

THE ASTA-CATH
Case of 12: $360.00

**EXPRESS DELIVERY AVAILABLE FOR AN ADDITIONAL CHARGE. CALL FOR CASE SHIPPING CHARGES.

P.O.Box 10, Haines Falls, NY 12436
Tel: (518) 589-6331 / Fax (518) 589-6332
Toll-Free: (888) 843-3334
Email:aplusproducts@aplusproducts.biz

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