Print and Fax Order Form

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 ____________________________________________________
Last Name ____________________________________________________
Street Address ____________________________________________________
Apartment Number ____________________________________________________
City ____________________________________________________
State ____________________________________________________
Zip Code or Postal Code ____________________________________________________
Country ____________________________________________________
Phone ____________________________________________________
Email Address ____________________________________________________
Circle Credit Card Type ____________________________________________________
Card Number ____________________________________________________
Expiration Date ____________________________________________________
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