Order Form
Please PRINT Clearly
| ----- Part 1 ----- | |||||||||||||||||
| Patient's Name: |
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| Size | |||||||||||||||||
Fabric Colors & Patterns: (* see below) |
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| Options: (**see below) | |||||||||||||||||
| ----- Part 2 ----- | |||||||||||||||||
| Shipping Address: |
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| ----- Part 3 ----- | |||||||||||||||||
Donation:
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*Fabrics: There are a variety of possible colors and patterns. The most common pattern themes include: flowers, butterflies, animals, all sports, music, animal prints, multi-color swirls, and designs for children. Every effort will be made to match your request.
**Options: Inside pockets are available by special order. These can hold items like surgical drains, tubing, or insulin pumps. Options increase the required donation.