To place an order, please print out this form, complete as desired, and mail it with your check to:
Please provide your following information:
Name:___________________________________________________________________________
Address:__________________________________________________________________________
City:__________________________________________State:_________Zip:__________________
Phone Number_________________________Email Address______________________________
Each MediBand™ set contains two bands (one goldtone and one silvertone) and one wallet card.
| MEDICAL CONDITION | QUANTITY | PRICE PER SET | AMOUNT |
| Diabetes | $7.95 | ||
| Diabetic - Insulin Dep | $7.95 | ||
| Diabetic - Oral Med | $7.95 | ||
| Diabetic - Insulin Pump | $7.95 | ||
| Diabetic - Diet Control | $7.95 | ||
| Adrenal Insuff. | $7.95 | ||
| Allergic Reaction | $7.95 | ||
| Asthma | $7.95 | ||
| Blood Thinner | $7.95 | ||
| Epilepsy | $7.95 | ||
| Heart Disorder | $7.95 | ||
| Kidney Failure | $7.95 | ||
| Latex Allergy | $7.95 | ||
| Medical Condition | $7.95 | ||
| Penicillin Allergy | $7.95 | ||
| Sales Tax (MD Residents Only) | $0.48 Per Set | |
|
| Shipping & Handling Per Order | $3.00 | ||
| Grand Total | |||
ID Technology thanks you for your business.