Supply Order Form

Please e-mail HCP@paxmanusa.com for any of the below items in digital versions. Please allow up to 14 days for your order to be prepared, packed and shipped.

Step 1 of 2

Please confirm if your site is IBBM or Self-Pay

(if not known please leave blank)

Insurance Based Billing Model (IBBM) - your site is directly billing patients’ insurance using scalp cooling CPT codes

Patient Self-Pay – your site has patients pay the Paxman Hub directly or using foundation funds and there is no billing to insurance

Shipping Recipient(Required)

Facility/Hospital name(Required)

Email(Required)

Shipping Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP

Cap Sizing Pack

3.5 Litre Coolant

Confirm the reason for the request of the 3.5 Litre coolant(Required)

1 Litre Coolant Refill

Supplied in 1 box containing 3 x 1 Litre Coolant

The Master Token

Forehead Protectors

(pack of 24) - Trim the size to best fit forehead (also included in patient cap kit) Only to be ordered if extras are required in the infusion suite.

Haircare Booster Pack

Hair Preparation Conditioner 200ml x 5
Paxman Forehead Protector x 5
200ml Continuous Spray Bottle x 5
Surgical Cap x 2
Envelope for Surgical Cap x 5

Drainage Kit

To be used in the event a Paxman scalp cooling system must be transported to relocate to another facility, and must be drained fully as part of the preparations

Tell me what I need to know - Scalp cooling patient manual

Information to encourage patients to take ownership of and optimize their scalp cooling treatment. Included in the Paxman Cap Kit patients will receive once fully enrolled

Help Me Decide - Scalp cooling patient manual

Information to encourage patients to take ownership of and optimize their scalp cooling treatment. Included in the Paxman Cap Kit patients will receive once fully enrolled

Information for Hairdressers

Tell me what I need to know - Scalp cooling patient manual - Spanish

Information to encourage patients to take ownership of and optimize their scalp cooling treatment. Included in the Paxman Cap Kit patients will receive once fully enrolled

Information for Hairdressers - Spanish

Desktop aid

A comprehensive desktop aid that covers important scalp cooling information designed for clinicians, including efficacy, safety and indications, patient motivations and outcomes as well as FAQs.

10 things to know about scalp cooling

A succinct summary of the key factors to know about scalp cooling. A useful overview or introductory piece to be shared with newly diagnosed patients.

Patient handout leaflet (IBBM)

A one page introductory summary of scalp cooling and available supportive resources. To be given to all newly diagnosed patients either in folders or at first oncologist appointment For IBBM sites this mentions insurance may cover, for patient self-pay sites the costs are listed on the back of the leaflet.

Patient handout leaflet (Insurance)

Facebook group poster

Awareness poster for the private Paxman Facebook Group

Patient Liaison cards - US

Awareness poster for the private Paxman Facebook Group

Patient Liaison cards - US - Jennie