Arizona customer order form for UK and Northern Ireland customers only.
You may either order and pay by credit card on-line or alternatively, print this page and enter your details (please print) and send to Arizona Healthcare, PO Box 5157, Chelmsford, CM1 6QF, (England U.K.)
| Order Code | Description | Size | Number required |
Price per item / pack. | Total price |
Order processing and Delivery to U.K. mainland destinations. Please add the correct amount to your order. See below for options. For delivery to other destinations, including the republic of Ireland, please use our on-line ordering service. |
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Order processing and standard
UK delivery for pants (not terry) booster pads & pins £3.50 |
Please enter the correct amount in the box above. | ||||
Please enter the total price of
your order, including order processing and delivery. |
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Your details. To ensure that we have interpreted your sizing requirements correctly and if you are ordering any of our made to measure garments, please enter your measurements here. When ordering our vinyl pants, please indicate if these are to be used with our terry towelling nappies. We will add a suitable additional allowance to your provided hip measurement.
| Hip (inches) | Waist (inches) | Top of leg circumference (inches) |
| For made-to-measure pants only | Depth of side seam | CPP only. For use with towelling nappies? Yes / No |
Important. If you are paying by credit card, to prevent fraudulent use, you must enter the credit card owner's details below. These will be checked by World Pay against the international card holder database.
| Name : Mr/Mrs/Miss | ||||
| Address 1 | ||||
| Address 2 | ||||
| Address 3 | ||||
| County / State | Post Code |
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| Country if not UK | ||||
| Please enter a contact telephone number (not
mobile). To prevent any embarrassment, we do not make calls to mobile phone numbers. |
Tel. No. | |||
If you are paying by credit card, please enter your details below, including the issue number if your card has one.
| Card No | |||||||||||||||||||||
| Start date (if applicable) | Expire date Essential | Issue No (if applicable) | |||||||||||||||||||
Card holder's signature
This order form containing your personal details will be shredded 1 year after your order has been processed.
Cash (UK currency only). For your security, this must be sent by registered post.
UK postal orders.
Most credit and debit cards (excluding American Express)
A cheque drawn on a UK bank. (Please allow for 5 full working days for us to
clear you cheque). For your safety, please cross them A/C payee only.