Order Page Form

 Instructions:     Complete this form on your computer:

       A) You may send this order form directly via the internet

       B) Print the form and FAX to: 201-794-7994

       C) Print the form and Mail to :

HydroStep™  Standoff Kit: (Plus Shipping)       HydroStep™ Kits:  0 1 2 3 4 5 6 7 8 9 10 @ $120.00/ kit

HydroStep™ Multi-Use Inserts (package of 3) 0 1 2 3 4 5 6 7 8 9 10 @ $18.00/ package of 3 inserts

Sound-Seal™ Protective Film Dressing** by Prescription ONLY   (10cm x 11.4 cm) (Plus Shipping)

10 Film Dressings @ $1.99/ Dressing($19.99)

25 Film Dressings @ $1.89/ Dressing ($47.25)

 Box of 50 Film Dressings:  0 1 2 3 4 5 6 7 8 9 10 @  1.79/Dressing  ($89.50 Per BOX)                        

 Case of 200 Film Dressings 0 1 2 3 4 5 6 7 8 9 10 @ $1.69/Dressing ($338.00 Per Case)

Sony Video Paper (UPP-110HG)

 VIDEO PRINTER PAPER - Each BOX has 5 ROLLS   -   No. of Boxes   0 1 2 3 4 5 6 7 8 9 10 @ $84.00/Box

(Best Price for High Glossy Paper)

Contact Name*  

Business Name* 

Address*

 City*            AL AK AZ CA CO CT DE DC FL GA HI ID IN IA KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WT WV State            Zip*

Telephone*:               Email*:          

 We will call you to confirm order.  Please have credit card available.

 *Required Fields

Doctor's License Number Required for SoundSeal™ film only**