Order Date

Appointment date*

Please enter the date of your upcoming scheduled treatment. If exact date is unknown please enter approximate date.

This will be treatment number*

Please enter the number of your next upcoming treatment.

Number of days for Shipping

Do you need to order a DeltaKit?

A DeltaKit must be ordered prior to first treatment

Yes - This is my first treatment and I need to purchase a DeltaKit
No - I have already purchased my DeltaKit

DeltaKit

Price:

Your DeltaKit will include your personal Cooling Wrap and Thermal Cap, as well as a detangling Wet Brush, spray bottle, and a Patient Guide.

State and Local Sales Tax

Sales Tax

Shipping Option

Your order qualifies for free regular ground shipping and should arrive in 4-5 days. If you need faster shipping, select a shipping option below.

Regular Ground
2 Day
Next Day

Shipping Option

Your scheduled treatment date requires 2 day shipping.

2 Day +40
Next Day +60

Shipping Option

Your scheduled treatment date requires next day shipping.

Next Day +60

Shipping Option

Pickup at Facility

Please pickup at your facility

DeltaCard Treatment Cards *

Each DeltaCard is valid for one treatment only. Additional cards can be purchased below or at a later time.

Price: $300.00

Required additional facility fees

Not Applicable

Shipping Option

Your order qualifies for free regular ground shipping and should arrive in 4-5 days. If you need faster shipping, select a shipping option below.

Regular Ground
2 Day +20
Next Day +40

Shipping Option

Your scheduled treatment date requires 2 day shipping.

2 Day +40
Next Day +60

Shipping Option

Your scheduled treatment date requires next day shipping.

Next Day +40

Shipping Option

Pickup at Facility

Please pickup at your facility

Total Cost

$0.00

Notes

Date

Patient Name

Total Treatments

Regimen

Regimen-Other

Medical Oncologist

St Dominic Jackson Memorial Hospital

Notes

Description