Name of Facility*
Name of Person Ordering*
Phone*
Email:*

Please skip this section if you are ordering supplies only

Your facility has a loaner vac in their facility which can be used until your communicare vac is delivered. Upon submitting this form you will receive a detailed email explaining how to return the loaner vac.

REQUEST A NEW VAC *
Request Return Label
Types
Details

ORDER SUPPLIES

AMD Gauze Pack
AMD Gauze Packing Strip
Bridge Kit
Cleanse Kit
DRESSINGS
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Case of Large Kits (15)
Case of Large Kits – 15
Case of Small Kits (15)
Case of Small Kits – 15
Large Kit
Individual Large Kits
Small Kit
Individual Small Kits
White Foam
Case of White Foam (10)
Large Oil Emulsion
Drapes (1)
Box of Drapes (10)
Extras Kit (Ostomy, Protective Barrier Wipes, Oil Emulsion)
Y Connector

DRAINS
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Suction Dome Drain
Case of Suction Dome Drian
Silver Mesh
CANISTERS
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Case of Canisters (20)
Case of Cansisters – 20
Canisters
Individual Canisters
Device Carrying Case
Carrying Cases
Power Cord
Power Cords

DELIVERY

Delivery Method