Professional Order Form
Name:
Clinic Name:
Clinic Address:
City:

State/Province:

Zip/Postal Code:
Mailing Address(if different from above):
City:

State/Province:

Zip/Postal Code:
Phone No.

Fax No.

E-mail:
Profession:
Order Placed By:

Method of Payment
COD

Visa

Master Card

Do not forward credit card numbers.  We will contact you after placement of order.
If a drop shipment, will the patient be paying for Invertrac? Yes No
Should we pass your cost on to the patient? Yes No
Ship to above address or drop ship to:
Patient Name:
Street Address for shipping:
City:

State/Province:

Zip/Postal Code:
Phone:
Fax:
E-Mail:
Mailing Address(if different from above):
City:
 State/Province:
Zip/Postal Code:
Phone Number:
 Fax Number:
 Email:
     
Comments:

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