The Dominican Village Daily Incontinence Program

Name *
Name
Address *
Address
Cell Phone *
Cell Phone
Gender
Emergency Contact Information
Phone
Phone
The Incontinence program consists of a full line of products discreetly delivered to your door, as a clinical treatment protocol .
(1) You will receive:

Gloves
100 pairs per box
1 Box per month


Wipes
200 per month
12 packages


Chux Pads
Up to 150 per month
23”x36 ”


Barrier Cream
(1) 4oz tube per month

(2) Please choose any combination of the below items, up to a total of 140:
Size
Size
Telivita will deliver monthly to each patient that takes part in this program . Telivita will work on best practices for the use of these products.
Other DME Products Offered by Telivita Order Form/ Price List :
Please Indicate if you would like to order: