Please tick the box of the size required. A maximum of three Pad Types can be ordered. Two pads will be issued per Pad Type. To place your order please send this form to the Independence Australia Customer Service team via fax 1300 788 811 or email [email protected]. Referral Details Full Name: Employer: Last First Phone: ( ) E-mail Address: Customer Details Full Name: Last First Address: House/Unit No. Street City State Postcode Phone: ( ) E-mail Address: Guards & Shields Absorption requirement: Low Moderate High Type: Male Female Brand: Brand: No Preference Booster Pads Absorption requirement: Low Moderate High Brand: Brand: No Preference Belted All In One (Nappy Style) Absorption requirement: Low Moderate High Waist measurement: Size requirement: Sml Med Lge Xlge Brand: Brand: No Preference Pull Ups Absorption requirement: Low Moderate High Waist measurement: Size requirement: Xs Sml Med Lge Xlge Brand: Brand: No Preference Stretch Pants Size requirement: Sml Med Lge Xlge Waist measurement: Brand: Brand: No Preference T 1300 788 855 | F 1300 788 811 | E [email protected] | W www.indepedenceaustralia.com Disposable Pad Sample Order Form