Select your Carpal Solution
1 Week Carpal Solution Therapy Pac (7 Disposable Devices)
Right Hand Quantity ____ $24.95 each (multiple quantity X $24.95) Sub Total _____ Line A
Left Hand Quantity ____ $24.95 each (multiple quantity X $24.95) Sub Total _____ Line B
2 Week Carpal Solution Therapy Pac (14 Disposable Devices)
Right Hand Quantity ____ $44.95 each (multiple quantity X $44.95) Sub Total ______ Line C
Left Hand Quantity ____ $44.95 each (multiple quantity X $44.95) Sub Total ______ Line D
6 Week Carpal Solution Therapy Pac (28 Disposable Devices)
Right Hand Quantity ____ $79.95 each (multiple quantity X $79.95) Sub Total ______ line E
Left Hand Quantity ____ $79.95 each (multiple quantity X $79.95) Sub Total ______ Line F
(Add lines A through F) PRODUCT TOTAL US $ _________
Shipping and Handling Options: (Check only one box and fill the amount in shipping total below)
US and Canada Ground $4.95 ______ USPS First Class Mail
2 Day Delivery US and Canada $15.95 ______ 2 Day Delivery shipped via UPS
United Kingdom, Australia, New Zealand, etc. $15.95 ______ USPS Global Priority Mail
SHIPPING TOTAL US $___________ line H
(Add lines G and H) TOTAL CHARGED TO CREDIT CARD US$___________ line I
Billing Information
All orders come with our Money Back Guarantee
| First Name |
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| Last Name |
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| Street Address |
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| Apartment Number |
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| City |
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| State |
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| Zip Code or Postal Code |
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| Country |
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| Phone |
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| Email Address |
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| Circle Credit Card Type |
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| Card Number |
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| Expiration Date |
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| CVV Number* |
____________________________________________________ |
*CVV Number: On Master Card or VISA, it is the last three digits on the back
of the card following your credit card number. On American Express, it is the
four digit number above the credit card number on the front of the card.
Shipping Information Place a check mark in parenthesis if same as Billing address: ( ___ )
| First Name |
____________________________________________________ |
| Last Name |
____________________________________________________ |
| Street Address |
____________________________________________________ |
| Apartment Number |
____________________________________________________ |
| City |
____________________________________________________ |
| State |
____________________________________________________ |
| Zip Code or Postal Code |
____________________________________________________ |
| Country |
____________________________________________________ |
Amount to be Charged to Credit Card US $ ________________ from Line I above
Card Holder Signature _______________________________ Date _____________
For timely processing, all order forms must be completely filled out with
the appropriate amount in US$, the form signed and dated by the credit card
holder of record.
FAX TO: The Carpal Solution FAX Number: 781-359-1845
Mail TO: First Hand Medical
Attention Customer Service
67 South Bedford Street
Suite 400 W
Burlington, MA. 01803 USA.
We accept Visa, Master Card, and American Express credit cards when ordering online,
by FAX, through the Mail or by phone. If you would like to pay by money order,
mail it with the order form to the address above.
We currently ship to the US and Canada, the United Kingdom, Australia and
New Zealand. If you are from another country, please contact us directly by email
at: relief@mycarpaltunnel.com
US FDA Registered
