CHECK AND MAIL TO:
Merri Zielenski
53 Bellhaven Road
Brookhaven, NY 11719
Logo
E-MAIL:
CaneCovers@gmail.com
PHONE:
(631)286-3842

ORDER FORM FOR QUAD TIP CANE

(FOR CANE WITHOUT REMOVEABLE RUBBER TIP
OR CANE WITH LARGE ADJUSTABLE PART)

Name_____________________________________________________________________________________________

Address_________________________________________City, State, Zip_______________________________________

Email address__________________________________________ Phone_______________________________________


CANE TYPE

Straight   or   Curved   (SELECT ONE)

Length of Cane in inches:                        (from base of handle to top of platform or rubber tip. You don't want the cover to go to the floor.)

Circumference in inches: just below handle                        

Circumference in inches: at adjustable point                        

FABRIC PATTERNS                                                                                                                                                                                                
AMOUNT DUE:

 

Starter Kit* $16.00 (Includes 1 cover)......................$                       

Cane Covers ($15 each or 3 for $42).....................$                        

Postage ........................................................................$        $4.00     

TOTAL...........................................................................$                        


*First time order requires one starter kit per cane and includes one cover (don't forget fabric choice for cover).
Additional orders for the same cane do not need starter kits or measurements (I keep measurements on file).