Project AIM Incontinence Product Information Form

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Please fill out form in full for pick up in Chilliwack, Abbotsford, Agassiz, Hope, or East Vancouver

Email *

Full Name *

Email Address

Address *

Phone Number

What location would you like to pick up from?

Chilliwack

Agassiz

Hope

Abbotsford

East Vancouver

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Is this your first time ordering from Project AIM?

Yes

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How did you find out about Project AIM?

Please select what color reusable incontinence underwear you would like (high rise, mild to moderate absorbency)

Beige

Black

I do not need any

Clear selection

Please select the size of reusable incontinence underwear you would like

XXL

I do not need any

Clear selection

Please select which style(s) disposable incontinence underwear you would like:

Pull-up style S/M

Pull-up style LG

Pull-up style XL

MENS pull-up style S/M

MENS pull-up style LG

MENS pull-up style XL

Tab Style (diaper) S/M

Tab Style (diaper) LG

Tab Style (diaper) XL

Tab Style (diaper) 2XL

Tab Style (diaper) 3XL

MENS anatomy specific pads (guards) for large surges

I do not need any disposable underwear

Please select what style(s) bedliner you would like:

Reusable bedliner

Disposable bedliner

I do not need a bedliner

Please select which size disposable incontinence pad(s) you would like:

#1 pad/liner (light)

#2 pad/liner

#3 pad/liner

#4 pad/liner

#5 pad/liner

#6 pad/liner

#7 pad/liner

Please select what item(s) below you would also like in your order

Barrier cream

Size M disposable gloves

Incontinence cleansing wipes

Questions or Comments:

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