How will you be paying?
Check
Money Order
Payable to Joseph A. Martell
Toll free 1-866-472-3990
Your mailing address:
Name
Address
State/Contry
Zip Code
Tel. #
(
)
Colostomizer
Qty.
$39.95 U.S.
Shipping and Handling
$4.95
Allow 2 weeks for delivery
Total
Make cheque payable to Joseph A. Martell
Please Enter:
Mail To:
Stoma size in Inches:
Pouch Name & No.:
Pouch Size:
Flange Name & No.
Flange Size:
Mardent Enr.
517 20th. Ave.
Deux-Montagnes (Quebec) Canada
J7R 4G9
