P O Box 183 PH (07) 865 9647

313 Casement Road Fax (07) 865 9649

Whangamata NZ Email:

Web:

ORDER FORM

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Comfy Bed Pads Add 1 long tuck-in flap (add $5.00 to price ) - Add 2 long tuck in flaps (add $10.00 to price)
PLEASE SELECT YOUR DELIVERY OPTIONS BELOW:
Postage & Packaging: (small parcels – less than $100 ) $6.00
Postage & Packaging: (Parcels – more than $100 ) $7.50
Postage & Packaging: North Island ( Parcels – more then $200 ) $12.00
Postage & Packaging: South Island (Parcels – more then $200) $17.00
If you are on ‘Rural Delivery’ ( Please allow an extra day for delivery) add $4.30
Please enclose cheque or fill out ‘credit card’ details below Total
Have you added the ‘delivery fee’ to your order????

Payment Details: Please tick box.

[ ] Cheque [ ] Credit Card [ ] Mastercard [ ] Visa

Expirey Date:______Card Holders Name:______

Card Number:______Card Secuity Code____

Please fill in these details: If you have ordered from us before – Please tick the following box [ ]

Age Group:[ ] under 40[ ] 40-60[ ]60-70[ ] 70-90

How did you first hear about Stay Dry Products? [ ]Through a friend [ ]Advertisement (please specify below)

[ ] Search Engine[ ] Yellow Pages [ ] Continence Nurse or District Nurse [ ] Other

If ‘other’ or ‘advertisement’ please specify______