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Cards Last Order

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This First Treatment Number

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Approaching Free Level

Appointment date*

Please enter the date of your upcoming scheduled treatment. If exact date is unknown please enter approximate date.

Number of days for Shipping

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 on Kit

Price:

DeltaCard Cost*

Each DeltaCard is valid for one treatment only. Multiple cards can be purchased at any time. Unused cards can be returned for a full refund.

Price:

DeltaCard Qty*

DeltaCard Cost*

Max payment reached, additional cards are $0. Each DeltaCard is valid for one treatment only. Additional cards can be purchased below or at a later time.

Price:

DeltaCard Qty*

ALERT! This order includes cards that should be in the free level. Please reduce the quanity until this message clears. After this you may place another order containing free cards.

Treatment Schedule

Please enter your treatment schedule for this order. You can use approximate dates if needed. The cost has been pre-filled with the cost of each DeltaCard ordered.

Treatment 1 Date

Treatment 1 Cost*

Treatment 2 Date

Treatment 2 Cost*

Treatment 3 Date

Treatment 3 Cost*

Treatment 4 Date

Treatment 4 Cost*

Treatment 5 Date

Treatment 5 Cost*

Treatment 6 Date

Treatment 6 Cost*

Treatment 7 Date

Treatment 7 Cost*

Treatment 8 Date

Treatment 8 Cost*

Treatment 9 Date

Treatment 9 Cost*

Treatment 10 Date

Treatment 10 Cost*

Treatment 11 Date

Treatment 11 Cost*

Treatment 12 Date

Treatment 12 Cost*

Treatment 13 Date

Treatment 13 Cost*

Treatment 14 Date

Treatment 14 Cost*

Treatment 15 Date

Treatment 15 Cost*

Treatment 16 Date

Treatment 16 Cost*

Treatment 17 Date

Treatment 17 Cost*

Treatment 18 Date

Treatment 18 Cost*

Treatment 19 Date

Treatment 19 Cost*

Treatment 20 Date

Treatment 20 Cost*

Treatment 21 Date

Treatment 21 Cost*

Treatment 22 Date

Treatment 22 Cost*

Treatment 23 Date

Treatment 23 Cost*

Treatment 24 Date

Treatment 24 Cost*

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Placeholder - Facility Fee

used to determine whether the required facility fee field displays on form

Required Additional Facility Fees*

Total Cost

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Order Summary

Date

Patient Name

Total Treatments

Regimen

Regimen-Other

Medical Oncologist

SKU

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Sales Tax

Weight	3 lbs
Dimensions	15 × 12 × 6 in

Test Facility SC -DELTA-2022

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ALERT! This order includes cards that should be in the free level. Please reduce the quanity until this message clears. After this you may place another order containing free cards.

Treatment Schedule

Notes

Order Summary

Description

Additional information