Today's Date
                                                                              Do you have insurance coverage for Ostomy supplies?
                                                                                                                   Yes
                                                                                                                    No
                                                                                 The name of the person who will use the supplies is:
                                                                                               
                                                                                 The name of the person who is making this request is:
                                                                                               
                                                                                                             Pouch needed is drainable? 
                                                                                                                      Yes
                                                                                                                       No
                                                                                                                       Closed pouch is desired
                                                                                                                       Yes
                                                                                                                       No
                                                                                                                            Pouch is urostomy? 
                                                                                                                       Yes
                                                                                                                       No
                                                                                   What brand of appliances are now used and preferred?
                                                                                                                Convatec? 
                                                                                                                 Hollister?   
                                                                                                                Coloplast? 
                                                                            Other? List Manufacturer
                                                                                  Can we substitute?
                                                                                                                       Yes
                                                                                                                        No
                                                    What size opening do you require in the wafer before you install it over your stoma?
                        (This is not the diameter of the mounting flange, this is the diameter of your stoma, the protrusion from your stomach)
                                                                                                                       
                                                                                                       What part number of the wafer is preferred? 
                                                                                                                       
                                                                                                                        What quantity is needed?
                                                                                                                       
                                                                                                       What part number of the pouch is preferred?
                                                                                                                       
                                                                                                                        What quantity is needed?
                                                                                                                       
                                                                                                  From our inventory listed, what items do you want?
                                                                                                                    
                                                                                                                    
                                                                                                                    
                                                                                                                                My shipping address is:
                                                                                                    Name
                                                                                      Street address:
                                                                                                    Apt. #:
                                                                                    City, State & Zip:
                                                                                                Phone #:
                                                                                                Mobile #:
                                                                             My E-mail address is:
                                                                                                           I will pay by check:
                                                                                                I will pay by money order:
                                                                                                     I  will pay by Visa Card:
                                                                                                                        Mastercard:
                                                                                                                   Discover Card: 
                                                                                                                      No cash please

Please tell us how you found Osto Group!

 I. If you are going to E-mail this form,
        1. Drag your browser over the information on the form, darkening it.
        2. Click on "control C"
        3. Close out the Internet.
        4. Open your E-mail.
        5. Open "New Mail".
        6. Put your browser in the information part of the E-mail form and click "Control V"
        7. Fill out the required information by double or triple clicking on each box so it will accept your entered           information.
        8. Enter "bpleski@comcast.net" in the "send to" box. Then click on "send".
    II. If you are going to fax this page, print the form, fill out the information and fax it to 530 432-3538.
    III. You can print this page and mail it to:
                Osto Group
                18962 Lake Forest Dr.
                Penn Valley, CA 95946-8818
    IV. You can also call Bob TOLL FREE at 877 678-6699 after you have reviewed the form and can explain to him what you need.