Patient Brochures. Patient Education Items Order Form ENGLISH
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1 Patient Education Items Order Form To place your order, please indicate the quantity you are ordering and the total price for each item. Once you order is complete, to or fax to Visit for more information and photos of each item. Patient Brochures We have an array of patient brochures available in different languages. There are only 5 languages listed on this form. If you would like to inquire about translated brochures in other languages, please amy@iuga. org or visit Most brochures are 8.5 x 11 tri-folds. ENGLISH Anterior Vaginal Repair Pack of 25 $8.25 $16.50 Bladder Training Pack of 25 $8.25 $16.50 Botulinum Toxin A Pack of 25 $8.25 $16.50 Constipation Pack of 25 $8.25 $16.50 Cystoscopy Pack of 25 $8.25 $16.50 Low Dose Vaginal Estrogen Therapy Pack of 25 $8.25 $16.50 Vaginal Hysterectomy for Prolapse Pack of 25 $8.25 $16.50 Interstitial Cystitis Pack of 25 $8.25 $16.50 Overactive Bladder Pack of 25 $8.25 $16.50 Pelvic Floor Exercises Pack of 25 $8.25 $16.50 Pelvic Organ Prolapse Pack of 25 $8.25 $16.50 Posterior Vaginal Wall Repair and Perineal Pack of 25 $8.25 $16.50 Body Repair Sacrocolpopexy Pack of 25 $8.25 $16.50 Sacrospinous Fixation Pack of 25 $8.25 $16.50 Stress Urinary Incontinence Pack of 25 $8.25 $16.50 Urodynamics Pack of 25 $8.25 $16.50 Uterosacral Ligament Suspension Pack of 25 $8.25 $16.50 Recovery Guide Pack of 25 $8.25 $16.50 Vaginal Repair with mesh Pack of 25 $8.25 $16.50 Urinary Tract Infection Pack of 25 $8.25 $16.50 Intermittent Self Catheterization Pack of 25 $8.25 $16.50 Sacral Neuromodulation Pack of 25 $8.25 $16.50 Page 1 of 5
2 CHINESE Anterior Vaginal Wall Repair Pack of 25 $6.25 $12.50 Hormone Replacement Therapy Pack of 25 $6.25 $12.50 Vaginal Hysterectomy for Prolapse Pack of 25 $6.25 $12.50 Posterior Vaginal Wall Repair Pack of 25 $6.25 $12.50 Sacrospinous Fixation Pack of 25 $6.25 $12.50 ITALIAN Anterior Vaginal Repair Pack of 25 $6.25 $12.50 Cystoscopy Pack of 25 $6.25 $12.50 Vaginal Hysterectomy for Prolapse Pack of 25 $6.25 $12.50 Interstitial Cystitis Pack of 25 $6.25 $12.50 Sacrospinous Fixation Pack of 25 $6.25 $12.50 PORTUGUESE Low Dose Vaginal Estrogen Therapy Pack of 25 $6.25 $12.50 Overactive Bladder Pack of 25 $6.25 $12.50 Page 2 of 5
3 SPANISH Cystoscopy Pack of 25 $6.25 $12.50 Low Dose Vaginal Estrogen Therapy Pack of 25 $6.25 $12.50 Overactive Bladder Pack of 25 $6.25 $12.50 PFD Anatomical & Surgical Chart Developed by the Public Relations Committee, this handy 8.5 x 14 flip chart with stand contains anatomical and surgical images from the popular patient leaflets. Item Name Pelvic Floor Dysfunction Anatomical & Surgical Chart Each $36.95 $49.95 Posters Poster Name Pelvic Organ Prolapse English Each $5.00 $10.00 Pelvic Organ Prolapse and Treatment Each $5.00 $10.00 English Other Items Item Name IUGAStix for POPQ Pack of 50 $25.00 $50.00 Illustration Pad Book of 100 $5.00 $10.00 IUGA Branded Polo Shirt Each $16.00 $32.00 IUGA Branded Baseball Cap Each $5.00 $ Page 3 of 5
4 IUGA Stix for POPQ Amount: $ Posters Brochures PFD Anatomical & Surgical Chart Illustration Pad If you are ordering for an IUGA member, please provide his/her name : Shipping Address: Billing Address: Name: Name: Address: Address: City: City: State/Province: Zip Code: State/Province: Zip Code: Check here if shipping and billing address are the same. PLEASE COMPLETE THIS FORM AND TO STORE@IUGA.ORG OR FAX TO Page 4 of 5
5 IUGA CREDIT CARD AUTHORIZATION FORM CREDIT CARD TYPE VISA MASTERCARD (one must be selected) AMERICAN EXPRESS CREDIT CARD NUMBER: EXPIRATION DATE: / / SECURITY CODE: DAY MONTH YEAR (MANDATORY) 3 digit code on signature strip of Visa or Mastercard (back) or 4 digit code on front of American Express CARDHOLDER NAME: BILLING ADDRESS: CITY: STATE/PROVINCE: COUNTRY: ZIP/POSTAL CODE: I hereby authorize IUGA to debit this credit card with the total amount of $ charges (cancellation/handling fees, substitution fees). and any subsequent Cardholder s Signature: (ORIGINAL SIGNATURE REQUIRED, DO NOT TYPE IN NAME) Date: PLEASE COMPLETE THIS FORM AND TO STORE@IUGA.ORG OR FAX TO ALONG WITH YOUR ORDER. Page 5 of 5
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