Page 20 - HSP-Assure Test Booklet FDA Auth Booklet - FINAL 8_2020
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                                                 2420 South 17th Street, STE C
                                                  Wilmington, NC 28401  USA               Contact us at:
                                                                                          (o) |  910.399.7380
                                                                                          (f) |  910.399.7381
                                               New Client Information                     sales@henslersurgical.com




                SHIPPING INFORMATION

                Company/Facility/Hospital


                Contact Name

                Title


                Contact Phone

                Address


                Suite / Building


                City / State / Zip

                Fax #


                Email

                BILLING  INFORMATION              Hensler Surgical Accepts Credit Cards or ACH Withdrawals


                Billing Desired         Circle one:    Credit Card (3% Fee)     ACH Withdrawal (No Fee)

                 Directions:

                 1 . Cre  dit  Ca  rd  a  nd  o  r  ACH  Withdrawal  Fo  rms  A  ttached

                                                                   f
                                       t
                 2 . Please  complete he   appro  priate  payment   or  Cre  dit  Ca  rd  o  r  A  CH
                                                                                       f
                                                  I
                                                                                             t
                 3 . Fax  c ompleted  New  Client nf  orm  ation  Form  a  nd  pa  ym  ent   orm o  1.910.399.7381
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