INTERNATIONAL ORDER FORM including EU MEMBER COUNTRIES Name: (Mr/Mrs/Miss/etc.)............................................. Age:........ Address...................................................................................... ................................................................................................. Post Code...........................Country..................................Date:............... Tel.No...........................Fax.No...........................email:............................ Please..... tick were applicable. Is this your first Sash belt, Yes........No........ Which of the SASH belts do you wish to order? STOMA SUPPORT AND HERNIA............ SECURITY AND LEAKAGE............UMBILICAL HERNIA......... Do you have a Colostomy............ Urostomy............ Ileostomy............. Stoma sited on your right hand side of your body.........or your left hand side of your body........ * Please enclose with this order form the following items or information. * A pouch you normally wear. If a 2-piece system, enclose both parts. * Waist size / belt length should be measured immediately above the hips, dipping slightly around the stomach and over the stoma, see inset on "F.A.Questions" page. * Inches....................cm's.....................The Hernia belt will be supplied with a Velcro fastening and has approximately 2-3 inches (50-75mm) of adjustment. * The price of the belt to all EU Member Countries is €45.00 Euros for the Stoma Support and Hernia belt * Or €30.82 Euros for the Security and Leakage Belt. Prices are inclusive of post and packaging. Euro cheques should be made payable to SASH * The price to all other Countries is £40.92 (GB Pounds Sterling) for the Stoma Support and Hernia Belt or £28.02 (GB Pounds Sterling) for the Security and Leakage Belt. Prices are inclusive of post and packaging Your personal cheque in local currency (equivalent to the Sterling price shown above) is acceptable and should be made payable to SASH. The above price includes the cost of Post and Packaging for each belt. Please post the above items (Order Form, Pouch and Cheque) to the address given below. SASH Woodhouse Woodside Road Hockley Essex, SS5 4RU, England Telephone / Fax: 0044 (0) 1702 206 502. Email: info@sashstomabelts.com Last information updated 01 January 2010