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Date

Hospital

Your Purchase Order Number

Name of Person Placing Order

Email Address

Telephone

Billing Address

Shipping Address

Quantity   Item Name                           Model    Price Per Unit    Total Price

                    $      $

                    $      $

                    $      $

                    $      $

                    $      $

                    $      $

Shipping:    FedEx Priority (Next Morning)      $35                    $

                 FedEx Next Day (By 3 PM)         $25                      $

                 FedEx 2nd Day                          $15                        $

                 FedEx 3rd Day                          $12                         $

                                                                   TOTAL                  $

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