Facility & Healthcare Providers Order Form
April 2016
HipSaver
April 2016
Call Us: 1-800-358-4477
Email Us: [email protected]
Name:
Facility Name:
Address:
Phone:
PO Number:
Returning customers need only to fill out "name", "facility", & "phone"
Nursing Home Models For Easy Dressing
Qty
Nursing Home Model (NH)
…..With Tailbone Pad (NHTB)
…..With Male Fly Front (NHFF)
…..With Male Fly Front With Tailbone Pad (NHFFTB)
Incontinence Management
XS
S
M
L
XL
XXL
XS
S
M
L
XL
XXL
44.99
Qty
Qty
Qty
Qty
Qty
Qty
Qty
M
M
M
M
S
S
S
S
S
S
XS
XS
XS
XS
Shorts Hip Only (Shorts-H)
Qty
S
S
S
S
XS
XS
XS
XS
XS
XS
Slim Fit (SF)
Slim Fit With Tailbone Pad (SFTB)
Slim Fit With Male Fly Front (SFFF)
Slim Fit With Male Fly Front With Tailbone Pad (SFFFTB)
Softsweat™ Shorts
Price
29.99
37.99
32.99
40.99
Price
34.99
27.99
34.99
42.99
39.99
47.99
Price
29.99
37.99
32.99
40.99
Price
39.99
XS
XS
XS
XS
Quick Change (QC)
Open Bottom (OB)
Open Bottom 3-Snap (OB3S)
Quick Change With Tailbone Pad (QCTB)
Wrap & Snap (WS)
Wrap & Snap With Tailbone Pad (WSTB)
Fashion Conscious Residents
Qty
Fax Us: 781-821-6514
Qty
M
M
M
M
M
M
Qty
S
S
S
S
Qty
Qty
L
L
L
L
Qty
L
L
L
L
L
L
Qty
M
M
M
M
Qty
Qty
XL
XL
XL
XL
Qty
XL
XL
XL
XL
XL
XL
Qty
L
L
L
L
Qty
XXL
XXL
XXL
XXL
XXL
XXL
XXL
XXL
XXL
XXL
Qty
XL
XL
XL
XL
Qty
XXL
XXL
XXL
XXL
Qty
Total
Total
Total
Total
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Shorts Hip / Tailbone Pad (Shorts-HT)
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Softsweats™
Hip Only - Under 5'7" Tall (Sweats-H-U)
Qty
XS
Qty
S
Qty
M
Qty
L
Qty
XL
Qty
XXL
Price
44.99
XS
S
M
L
XL
XXL
44.99
XS
S
M
L
XL
XXL
49.99
XS
S
M
L
XL
XXL
49.99
XS
S
M
L
XL
XXL
69.99
XS
S
M
L
XL
XXL
69.99
XS
S
M
L
XL
XXL
74.99
XS
S
M
L
XL
XXL
74.99
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Hip Only - Over 5'7" Tall (Sweats-H-O)
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Hip / Tailbone - Under 5'7" Tall (Sweats-HT-U)
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Hip / Tailbone - Over 5'7" Tall (Sweats-HT-O)
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Hip / Knee - Under 5'7" Tall (Sweats-HK-U)
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Hip / Knee - Over 5'7" Tall (Sweats-HK-O)
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Hip / Tailbone / Knee - Under 5'7" Tall (Sweats-HTK-U)
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Hip / Tailbone / Knee - Over 5'7" Tall (Sweats-HTK-O)
Enter Color Code: N=Navy, G=Gray, F=Forest Green
Underwear Shipping: 1-5 units: $9.99, 6-8 units: $11.99, 9-13 units: $13.99
Softsweats Shipping: 1-3 units: $10.99, 4-8 units: $12.99, 9-13 units: $14.99
Over 13 units call for shipping estimate otherwise we ship best method.
(If ordering underwear and softsweats choose
softsweats shipping cost)
www.hipsaver.com
Shipping
Total
Total