Splint Order Form

Send this completed order form along with the negative arm cast to:

J & L Rehab Medical Supplies

#201-383 Ellis Street

Penticton, BC

Canada V2A4L9

Allow 2-3 weeks for splints to be returned by Canada Post. Please make cheques payable to:

J & L Rehab Medical Supplies

Deduct $5.00 from the cost of subsequent splints made on same cast.

Casts are kept for three months. Prices effective January, 2008 and are subject to change.

Please provide the following contact information:

Client Name:

Occupational Therapist:

O.T.'s Address:

Address (cont.)

City

State/Province

Zip/Postal code

Country

Work Phone

FAX

E-mail

URL

Do you have a Physicians referral for the splint(s)?

Yes No

Splint Style:

Wrist Splint
C.M.C. Splint
Wrist and Thumb Splint

Material

Polyethylene

Leather (with Poly reinforcement) Regular Leather-2 layers of 3 oz.*

Leather (with Poly reinforcement) Medium Leather-2 layers of 5 oz.

Leather (with Poly reinforcement) Heavy Leather-2 layers of 7 oz.

*Black leather is available for surcharge. It is only used for the outside layer and only available in 3 oz leather

PRICE PER SPLINT

CMC SPLINT Poly $60.00

Leather -regular weight $75.00

-medium weight $84.00

-heavy n/a

WRIST SPLINT Poly $68.00

Leather -regular weight $97.00

-medium weight $112.00

-heavy $120.00

WRIST & THUMB SPLINT Poly $78.00

Leather -regular weight $111.00

-medium weight $117.00

-heavy n/a

RUSH ORDER add $15.00

(put in return mail within 7 days of receiving cast)

BLACK LEATHER $10.00

GOODS & SERVICES TAX (GST) 7%

TOTAL

BILLING

Purchase order #

Account name

ADDRESS FOR SPLINTS TO BE SHIPPED

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Country

Send this completed order form along with the negative arm cast to:

BACK

copyright 2007 J & L Rehab Medical Supplies

Last revised: 13 April 2010

Client Name:
Occupational Therapist:
O.T.'s Address:
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail
URL

PRICE PER SPLINT
CMC SPLINT	Poly		$60.00
	Leather	-regular weight	$75.00
		-medium weight	$84.00
		-heavy	n/a
WRIST SPLINT	Poly		$68.00
	Leather	-regular weight	$97.00
		-medium weight	$112.00
		-heavy	$120.00
WRIST & THUMB SPLINT	Poly		$78.00
	Leather	-regular weight	$111.00
		-medium weight	$117.00
		-heavy	n/a
RUSH ORDER add				$15.00
(put in return mail within 7 days of receiving cast)
BLACK LEATHER				$10.00
GOODS & SERVICES TAX (GST)				7%
TOTAL

	ADDRESS FOR SPLINTS TO BE SHIPPED
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country