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/ Dignity Health – St Marys -DELTA-
Dignity Health – St Marys -DELTA-
Order Date
MM slash DD slash YYYY
Appointment date
*
Please enter the date of your upcoming scheduled treatment. If exact date is unknown please enter approximate date.
MM slash DD slash YYYY
This will be treatment number
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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22
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24
Please enter the number of your next upcoming treatment.
Number of days for Shipping
Do you need to order a DeltaKit?
A DeltaKit must be ordered prior to first treatment
Yes - This is my first treatment and I need to purchase a DeltaKit
No - I have already purchased my DeltaKit
DeltaKit
Price:
Your DeltaKit will include your personal Cooling Wrap and Thermal Cap, as well as a detangling Wet Brush, spray bottle, and a Patient Guide.
State and Local Sales Tax
Price:
$0.00
Shipping Option
Your order qualifies for free regular ground shipping and should arrive in 4-5 days. If you need faster shipping, select a shipping option below.
Regular Ground
2 Day
Next Day
Shipping Option
Your scheduled treatment date requires 2 day shipping.
2 Day +40
Next Day +60
Shipping Option
Your scheduled treatment date requires next day shipping.
Next Day +60
Shipping Option
Pickup at Facility
Please pickup at your facility
DeltaCard Treatment Cards
Quantity
*
Each DeltaCard is valid for one treatment only.
Additional cards can be purchased below or at a later time.
Price:
$300.00
Quantity
Required additional facility fees
Not Applicable
Required additional facility fees
250 Per Treatment Capping Service Fee
Required additional facility fees
150 Per Treatment Capping Service Fee
Required additional facility fees
100 Per Treatment Capping Service Fee
Required additional facility fees
75 Per Treatment Facility Fee
Required additional facility fees
100 Per Treatment Facility Fee
Shipping Option
Your order qualifies for free shipping and should arrive in 2-4 business days. If you need faster shipping, select a shipping option below.
FEDEX 2DAY
FEDEX STND OVRN
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Shipping Option
Your scheduled treatment date requires 2 day shipping.
Not Applicable
Shipping Option
Your scheduled treatment date requires next day shipping. There is a $40 fee for this expedited shipping.
FEDEX STND OVRN
Shipping Option
Pickup at Facility
Please pickup at your facility
Total Cost
$0.00
Notes
Notes
Order Summary
Date
MM slash DD slash YYYY
Facility Name
Patient Name
Total Treatments
Regimen
Regimen-Other
Medical Oncologist
SKU
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Sales Tax
Dignity Health - St Marys -DELTA- quantity
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SKU:
CA-2155d
Category:
West
Tags:
Delta
,
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Description
Description
Dignity Health – St Mary’s
San Francisco, CA
cap 9
