Hug Wraps® Order Form

Hug Wraps® Order Form
Your Name:

Your First NameLast Name
Phone Number:

Area CodePhone Number
Email:
Relationship:
What is your relationship to the patient?
Patient Information
Patient Name:

First NameLast Name
Upcoming Surgery?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearIf the patient has an upcoming surgery, let us know the date
Age
Height:
Diagnosis:
Gender:
Size:

Other

Gown Design
Fabric:
Colors:
Please list the patients 3 favorite colors
Patterns:
Please list the patients 3 favorite patterns
Customize your Hug Wraps® with the following options. Please note that these options are available for an additional donation. Please note that floor length Hug Wraps® are NOT available.

Inside Pockets can hold items like surgical drains, tubing or insulin pumps. Thigh Length Hug Wraps® are best for Breast Cancer patients. Knee Length are perfect for patients with ovarian, colon or pancreatic cancer.
Additional Add-ons:
Any Additional Thoughts You Would Like to Share?

Patient Information