3230 S Ambrosia Dr.
Chandler AZ 85248
888-364-8721 or 866-546-1988
FAX 866-546-1989
info@dmi.phxcoxmail.com

Custom Garments - Authorization Request Form

The Medical Compression Garment(s) needed for your upcoming procedure requires special alterations.

Due to unique requirements and alterations for your specific needs, we request that these garments are prepaid in advance of shipping.

This is a NON-REFUNDABLE deposit and only applies to cancellation of your procedure. DMI guarantees all products are free of defects caused by materials or workmanship.

If you have any questions or concerns, please feel free to contact us at 888-364-8721.

Please complete the form below and submit your Custom Garment Authorization request. Please note that the credit card information you use must be the name, address, etc. on the credit card billing statement for that credit card.

Authorization Form*Indicates Required Fields
First Name *
Last Name *
Email
Phone *
Fax
Street Address *
Street Address 2
City *
State/Province *
Postal Code *
Country
Custom Garment Details *
Custom Garment Authorization and Consent:
By selecting the "I AGREE" button and clicking on the "Submit", You acknowledge and agree that You are entering into a binding contract with DMI Medical for prepayment of your altered compression garment(s) and to be bound by the terms and conditions of the Agreement. PLEASE READ THE AGREEMENT CAREFULLY. If you are not willing to be bound by the terms and conditions of the agreement, click the "I DECLINE" button and do not seek to obtain the services of DMI Medical.

I AGREE I DISAGREE
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