ORDER FORM

Call 1 (419) 358-8003 with questions.

NOTE: Call or e-mail 'rcs@wcoil.com' for Ostomy Support Group or Distributor Pricing for all products listed!
Free shipping applies to all domestic orders, for orders outside the U.S. please contact us regarding shipping.

Qty. Item Price Per Item TOTAL
STOMA CUP
FREE with purchase of either "Rosie" or any Handi-Ring!
(For Cup only purchases, the following prices shown apply.) 		1 @ $10.00
2 @ $6.75 ea.
3 @ $5.00 ea.
 $

"RING AROUND THE ROSIE " #125
Must be used with Ostomy Belt and 1-3/4" pouch. (For stomas 1/2" to 1-1/4" diameter or irregular shape.)

1 @ $38.00
2 @ $33.00 ea.
3 @ $30.00 ea.
 $

"RING AROUND THE ROSIE " #175
Must be used with Ostomy Belt and 2-1/4" pouch. (For stomas 1/2" to 1-3/4" diameter or irregular shape.)

1 @ $43.00
2 @ $38.00 ea.
3 @ $35.00 ea.
 $
HANDI-RING #100
If your stoma is up to 1" in diameter, you must use with a 1-1/2" pouch flange. (38mm) 		1 @ $20.00
2 @ $17.00 ea.
3 @ $15.00 ea. 		$
HANDI-RING #125
If your stoma is between 1" and 1 1/4" in diameter, you must use with a 1-3/4" pouch flange. (45mm) 		1 @ $25.00
2 @ $20.00 ea.
3 @ $18.00 ea. 		$
HANDI-RING #175
If your stoma is between 1 1/4" and 1 3/4" in diameter, you must use with a 2-1/4" pouch flange. (57mm) 		1 @ $30.00
2 @ $25.00 ea.
3 @ $22.00 ea. 		$

Please note: as all items listed are considered a personal medical product, we are unable to accept returns for replacement of another size.
Further: RCS Company is not a Medicare Provider and therefore does not bill Medicare. If you are a Medicare recipient you must assume complete financial responsibility for your RCS purchases.

Grand Total $
Please send my order to:
NAME:
EMAIL:
ADDRESS:
CITY:
STATE:
ZIP CODE:
VISA/MASTERCARD:
EXP. DATE:
NOTE: If you do not want to send your credit card number via the net, you may complete, print, and fax the order form to (419)358-7957.
Thank you for ordering your RCS Co. products. Your order will be sent immediately.

                        

If required, further information may be obtained by contacting the RCSCOMPANY via E-mail or U.S mail:

E-mail: rcs@wcoil.com

RCS Company
P.O. Box 226
Bluffton, Ohio 45817-0226

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