Elixir Medical Shields

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Emergency Shield Upgrade Order form

Please complete the form below and press send mail at bottom of the page

Please ensure all details are correct. Elixir Shields or associated parties or persons cannot be held responsible for any omissions or mistakes supplied on this form

Disc Number:
Mr Mrs Miss
Surname:
Full Name:
Email Address
ID Number

Contact Details:

Phone (Home)
Phone (Work)
Cell
E-Mail

Emblem Order Form Stainless Steel

Ladies Emergency Bracelet	R 100.00 inc. Vat & Postage
Gents Emergency Bracelet	R 100.00 inc. Vat & Postage
Emergency Neck Disc and Chain	R 100.00 inc. Vat & Postage
Ladies Diabetic Bracelet	R 100.00 inc. Vat & Postage
Gents Diabetic Bracelet	R 100.00 inc. Vat & Postage
Diabetic Neck Disc and Chain	R 100.00 inc. Vat & Postage

Please click on desired payment method

Option 1: Payment by Debit Order
If you have an existing debit order for your annual subscription you can authorise Elixir to draw this payment from your bank account i (name)
Identity Number by completing this section hereby authorise Elixir to draw (Rands) from my bank account on my existing debit order lodged with Elixir, for my new upgrade disc

Option 2: Payment by Electronic Transfer / Direct Deposit
You can deposit directly into the Elixir bank account Bank Details Account Name: Elixir Bank: ABSA Account Number: 4055031468 Branch Code: 510829

Option 3: Post a Cheque to Elixir Elixir P.O. Box 683 Umhlanga Rocks 4320

Please Note No upgrade will be processed before proof of payment is received. Proof of payment must be faxed to 0860 103 684 Always include your existing disc number as a reference on all faxes, deposits and correspondence.

Send me a carbon copy of this email.

Please complete the form below and press send mail at bottom of the page

Emblem Order Form

Stainless Steel

Please Note