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) PLEASE CHOOSE FROM EACH OF THE FOLLOWING ITEMS YOU WANT TO RECEIVE:
GLOVES
VINYL AND POWDER-FREE 100 PAIRS PER BOX
WIPES
1 PACKAGE CONTAINS 50 WIPES
CHUX PADS
EACH BOX CONTAINS 150 - 23" X 36" PADS
BARRIER CREAM
ONE 4 OZ. TUBE


(2) Please choose any combination of the below items, up to a total of 140:
SIZE
SIZE
LINERS
EACH PACKAGE CONTAINS 25 LINERS


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: