MAIL P.O. Box 333 Harwich, MA 02645	PHONE 508-430-2410	FAX, TTD 508-430-2410	E-Mail specialclo@aol.com

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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 ___

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Bibs | Adult Bodysuits | Adult Knit Pants | Adult Briefs | Travel Cath | Adult Jumpsuits | Adult Snap Front Sleeper | Adult Swim Diaper

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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__________________________________

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 _______

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item #	Description	Qty	Size	Color	Option #	Option Charges	Price @	Total Price

SHIPPING & HANDLING	Subtotal	______________
United States & Puerto Rico ...$6.00 for orders under $100.00 For orders over $100.00, please add $7.00 for shipping
International shipping costs will be billed IN ADVANCE of order shipment	Shipping	______________
	Total Order	______________

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Address________________________________    City_________________ ST ____ Zip_________

Name ____________________________________________

Address________________________________    City_________________ ST ____ Zip_________

Name ____________________________________________

Address________________________________    City_________________ ST ____ Zip_________

Name ____________________________________________

Address________________________________    City_________________ ST ____ Zip_________

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