Individual Adaptive Clothing Request |
| We do our best to fulfill your order as listed from available stock on hand. Substituitions may be sent. |
| Name (First and Last)(required): | | Enlistment Date (required): | |
| Shipping Address (required): | |
| Shipping Address 2: | |
| Shipping Address 3: | |
| City (required): | | State (required): | | Zipcode (required): | |
| Phone (required): | | Email (required): | |
Show Pants adapted in which way? Left
Right
Double
Wheel Chair
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Show Shirts adapted on which side? Left
Right
Double
Left Shoulder & Double Torso
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Comfort AccessoriesPlease limit yourself to one comfort item of each type. |
| Quantity |
| Bedrail Organizer | |
| Lap Robe | |
| Personal Pillow w/ Case | |
| Transport Bag | |
| Fixator and Foot Cover | |
| Comments | |
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