Hug Wraps® Order Form

Hug Wraps® Order Form
Your Name: *

Your First Name Last Name
Phone Number: *

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

First Name Last Name
Upcoming Surgery?

Month Day Year
If the patient has an upcoming surgery, let us know the date
Age *
Height: *
Diagnosis:
Gender: *
Size: *

S M L XL 1X

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:

Inside Pocket Knee Length Patient has port
Any Additional Thoughts You Would Like to Share?

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Patient Information