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Mount Sinai West -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
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4
5
6
7
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9
10
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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
Not applicable
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
Total Cost
$0.00
Notes
Notes
Patient Name
Total Treatments
Regimen
Regimen-Other
Medical Oncologist
Subtotal
Options
Total
Mount Sinai West -DELTA- quantity
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SKU:
NY-2035d
Category:
Northeast
Tags:
Delta
,
Invoice
,
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Description
Description
Mount Sinai West
