ORDER FORM
AC MEDICAL SUPPLIES
Please return this form with the necessary information. Please
write very legibly to avoid problems
with incorrect address or lost parcels.
Last Name:___________________________ First Name: ________________________
Full Address: ____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
E-mail: ________________________________________________________
Please list all items you wish to purchase:
_________________________________________________________________________
Item number #: Description
/ Color:
Size:
Quantity:
Price:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________
POSTAGE FEE. Please add postage: in the USA,
US $ 14. In Canada, Can $ 13.
Other countries: US $ 18 (or 15 euro)
____________________________________________________
TOTAL: ______
Please enclose the payment with your order. If possible, please
pay with a money order (as sold in
the post office, or by large banks), or with traveller's checks.
Cash payments (in paper currency)
are also acceptable, however, they are mailed at your own risk.
Sorry, no credit cards accepted, at this time.
Mail to: AC MEDICAL SUPPLIES, Post Office
Box 29011, Westmount Mall, London,
Ontario, Canada N6K 4L9
If needed, contact us by mail or e-mail (acms@acmedi.com).
AC Medical Supplies - manufacturer,
wholesaler, and retailer of hygienic garments for medical patients and
disabled persons.
Registered with the Ministry
of Consumer and Commercial Relations, Province of Ontario, Canada.
Return to AC Medical main homepage or to the AC Medical main catalog .