MAIL
P.O. Box 333
Harwich, MA 02645

PHONE
508-430-2410

FAX
508-430-2410

E-Mail
specialclo@aol.com
Print this page, fill in your order requirements, then mail or fax the form to us - Thank You!
Are You a(n):   Individual ___   Institution ___   School ___   Wholesaler ___   Professional ___
Bibs | Bodysuits | Bottoms | Briefs | Diapers | Flannel Diapers | Footwear | Jackets | Jumpsuits | Mittens | Overpants | Ponchos | Swimwear | Tee Shirts | Travel Cath
ORDERED BY:

Name____________________________________

Address_________________________________

City________________State_____Zip__________

 SHIP TO (If different):

Name____________________________________

Address_________________________________

City________________State_____Zip__________

PHONE (In case we have questions about your order): Day_____________ Eve_____________

E-Mail: Day______________________________    Eve_______________________________

METHOD OF PAYMENT:(U.S. Currency only - Sorry no C.O.D.'s Accepted)

     ____ CHECK OR MONEY ORDER ENCLOSED, PAYABLE TO "SPECIAL CLOTHES"
     ____ NET 30 DAYS (Institutions only)
  ____ VISA

  ____ MASTERCARD
      CARD NUMBER _______________________________

     EXPIRATION DATE (MM/YY)____________

     SIGNATURE__________________________________

Child's Name & Birthdate:___________________________________________________________
       PLEASE INCLUDE THIS INFORMATION TO RECEIVE A 15% DISCOUNT COUPON, SENT ON THE CHILD'S BIRTHDAY

ADDITIONAL INFORMATION:
Please include any other information relevant to your child's clothing needs (wheelchair use, G-Tube, Trach, type of brace, Paralysis, etc.)

______________________________________

______________________________________

______________________________________

______________________________________		 ARE YOU ORDERING A G-TUBE ACCESS OPENING? If so, please let us know where to place it.

a) Inches from the shoulder to site _______

b) Inches from the left side to site _______


item
#
Description
Qty
Size
Color
Option
#
Option
Charges
Price @
Total
Price
          
          
          
          
          
          
          
          
          
          
          
          
SHIPPING & HANDLING Subtotal ______________
United States & Puerto Rico ...$5.00 for orders under $100
Orders over $100.00...please add $6.00 for shipping.		 15% Birthday Discount * ______________
International shipping costs will be billed IN ADVANCE
of order shipment		 Shipping ______________
  * Please enclose 15% Birthday Discount coupon Total Order ______________

Do you know anyone who might like to receive a free copy of the Special Clothes Catalogue?

Name ____________________________________________

Address________________________________    City_________________ ST ____ Zip_________

Name ____________________________________________

Address________________________________    City_________________ ST ____ Zip_________

Name ____________________________________________

Address________________________________    City_________________ ST ____ Zip_________

Name ____________________________________________

Address________________________________    City_________________ ST ____ Zip_________

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