To place an order, please print out this form and mail it with your check to:
I.D. Technology, Inc.
117 Nelson Road
Baltimore, MD 21208-1111
Phone : (410) 602-1911 ..eMail : support@id-technology.com
Name:____________________________________________________________________
Address:_________________________________________________________________
City:_______________________________State:_________Zip:__________________
Email Address:_______________________________________________________
Phone Number_________________________________________________________
Each MediBand Kit contains one goldtone band,
one silvertone band, and one medical wallet card
KIT STYLE----------------- QTY --------- PRICE EACH ---------- AMOUNT----
Diabetes- Wallet Card________________________$7.95________________________
Diabetic- Insulin Dep________________________$7.95________________________
Diabetic- Oral Med___________________________$7.95________________________
Diabetic- Insulin Pump_______________________$7.95________________________
Diabetic- Diet Control_______________________$7.95________________________
Adrenal Insuff.______________________________$7.95________________________
Allergic Reaction____________________________$7.95________________________
Asthma_______________________________________$7.95________________________
Blood Thinner________________________________$7.95________________________
Epilepsy_____________________________________$7.95________________________
Heart Disorder_______________________________$7.95________________________
Kidney Failure_______________________________$7.95________________________
Latex Allergy________________________________$7.95________________________
Medical Condition____________________________$7.95________________________
Penicillin Allergy___________________________$7.95________________________
Sales Tax ( Maryland Residents ONLY) ___$0.48 per Kit________________
Shipping and Handling _____$3.00___
TOTAL $____________