A division of Redbridge Distribution LLC MONTHLY SUPPLY AGREEMENT Responsible Party Name (Primary Contact)(Required) First Last Email(Required) Phone(Required)Relation to Resident(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is there a 2nd Responsible Party? No Yes Responsible Party Name (Secondary)(Required) First Last Email Phone(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Consent(Required)I/we ("Responsible Party Name, Primary Contact and/or Secondary Contact", "Resident") hereby agrees to enroll in automatic supply replenishment for all supplies related to my or my loved ones care. I/we understand and acknowledge that the facility/care home will monitor the quantity of supplies and inform me/us of any changes to the current monthly minimum quantities they need on hand. If there is no change in the supply quantity, the subscription will automatically fill on the pre-determined order date each month. All orders include the following list of supplies: I agree... Adult Briefs - Pull-Ups for the daytime - Tabbed Briefs for evening and overnight - Optional: Pads Disposable bed pads - Optional: Washable bed pads (facility-specific) Adult sanitary wipes Nitrile Gloves (4 boxes per order) Calmoseptine Odor Control - PH Cream - Bye Bye Odor Enzyme spray Responsible Party AuthorizationSignature(Required) Δ
