So that we can process your order please fill out the following Order Form in full. You will need to read and agree to both Medical Specialties of California's Rental Agreement and Disclaimer. Please read both of these and make sure you understand them.
YOUR DETAILS
Name
Address
Town
City
State
Zip Code
Telephone Number
Cell Number
email Address
User's Age?
Is the user male or female?
YOUR TREATMENT
What Cancer is being treated?
Date of first Chemo
What drug regimens will be used?
What are the dosages per metre squared for each drug?
What are the infusion times for each drug?
What is the period of time between each round of chemotherapy treatment?
How many chemotherapy treatments will be administered?
OTHER INFORMATION
What type of hair does the user have?
(Please choose one for each option)
What colour is the user's hair?
If the user's hair is fine or thin is there lots of hair or little amount of hair?
Is the user a vegan?
Is the user using a deodorant containing Aluminium?
Does the user have any liver impairment?
Name of your Chemo Centre?
Zip Code of your Chemo Centre?
Name of your Oncologist?
ORDER FORM
Please arrange for shipment of (Please tick box) A set of Penguin Cold Caps
A set of Head Bands, for larger heads (not usually supplied)
Helpful Information
Date to be delivered by
I have read and agree to Medical Specialities of California UK Ltd's Penguin Cold Cap Rental Agreement (click here to read)
I have read and agree to Medical Specialities of California UK Ltd's Disclaimer (click here to read)
I authorise Medical Specialties of California UK Ltd to deduct the monthly rental fee, initial security deposit and packing and shipping charges, if applicable, from the credit card detailed below.
Card holder's name as shown on card
Card Type (eg: Mastercard, Visa. Please note we do not accept American Express)
Card Number
Start Date (Where applicable)
Expiry Date
3 Digit Card Security Number
Billing Address (as shown on the credit card statements)

It will be necessary to contact your credit card company to verify the overseas transaction from Medical Specialties of California
A charge of £20.00 will be levied for a failed payment application
It will be necessary to contact you credit card company to verify the overseas transaction for Medical Specialties of California UK Ltd (a United Kingdom Registered Company). A charge of £20.00 will be levied for a failed payment.

Any information you give us will be treated in the strictest of confidence and is never sold or passed to any other company