Canadian Order Form

Wrong form?
| Canadian | United States | International |

Sold To:

Name:

*

Address:

City:

Province:

Postal Code:

Email:

*

Confirm Email:

*

Ship To:

Same

Name:

Address:

City:

Province:

Postal Code:

Remember my information on this computer. (Clear this box if you are on a public computer)

Note: Fields marked with a * are mandatory.

QuantityItemPatternBeltUnit PriceTotal
   
   
   
   
   
   
   
   
   
   

Product Total:
Shipping and Handling:
Total:

Payment will be made by: Cheque Credit Card

Insulin Pump Make & Model:

Other Notes:

Ordering Notes

Receipt of order will hold product for two weeks. Product will be shipped upon receipt of payment.
Your order will be confirmed via the email you specified. If you do not receive a confirmation within three days, please email us directly.

If you are paying by Credit Card, you will receive a PayPal confirmation in a few days.


PayPal Verified Logo is a
trademark of PayPal Inc.

Shipping and Handling Notes

Product TotalShipping Total
Up to $20.00$9.00
$20.01 to $40.00$9.50
$40.01 to $60.00$10.00
$60.01 to $80.00$10.50
$80.01 to $150.00$11.50
Over $150.00FREE

Shipment made via Canada Post XPressPost™, but can be upgraded at an additional cost.

Returns will not be accepted on custom orders.
Customers are responsible for any additional taxes or duties.

Return home
Email Questions or Comments