Medical-grade supplies at membership warehouse prices! MONTHLY SUPPLY AGREEMENT Responsible Party Name (Primary Contact)(Required) First Last Email(Required) Phone(Required)Relation to Resident(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is there a 2nd Responsible Party? No Yes Responsible Party Name (Secondary)(Required) First Last Email Phone(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Consent(Required)I/we ("Responsible Party Name, Primary Contact and/or Secondary Contact", "Resident") hereby agrees to enroll in automatic supply replenishment for all supplies related to my or my loved ones care. I/We understand a receipt for all required supplies purchased will be provided, access to view and manage the orders via the purchase account portal. I/we understand and acknowledge that the facility/care home will monitor the quantity of supplies and inform me/us of any changes to the current monthly minimum quantities they need on hand. If there is no change in the supply quantity, the subscription will automatically fill on the pre-determined order date each month. All orders include the following list of supplies: I agree... Adult Briefs - Pull-Ups for the daytime - Tabbed Briefs for evening and overnight - Optional: Pads Disposable bed pads - Optional: Washable bed pads (facility-specific) Adult sanitary wipes Nitrile Gloves (4 boxes per order) Calmoseptine Odor Control - PH Cream - Bye Bye Odor Enzyme spray I/we understand that we will have access to the order portal to view all supplies being ordered on our behalf and supplied a copy of each paid invoice.Responsible Party AuthorizationBy signing here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By signing here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address and phone number in order to contact you regarding any changes, if necessary.Signature(Required) Δ
