Page 21 - HSP-Assure Test Booklet FDA Auth Booklet - FINAL 8_2020
P. 21
2019-nCoV IgG/IgM Rapid Test Cassette
Order Form
Hensler Surgical Technologies
2420 South 17th Street Date of Order:
Suite C Order Number:
Wilmington, NC 28401
Submit Orders to: sales@henslersurgical.com
Customer Info:
Account Name: ______________________________ Distributor: Hensler Surgical Technologies
Contact Name: ______________________________ Distributor Contact: 910.399.7380
Contact e-mail: _______________________________ Distributor Number: 910.599.4885
Contact Number: _____________________________ Sales Rep: _______________________
Quantity Description Unit Price Amount
Assure Tech CoV-19 Test Kit
Total:
Shipping Method
FedEx: Pick Up
Date to Receive: ______________________________ Date of Pick Up: ____________________
Ship to Address: ______________________________ Time of Pick Up: ____________________
Address 2: ___________________________________ By: ______________________________
City: ___________________ _________
Zip:
State: ________________________
Healthcare Provider/ Group to Read Tests : CLIA Lab to administer the Assure test :
(Must Fill in Below) (Must Fill in the CLIA number Below)
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F FedEEx Nextt Daay 100::330 ( (Freee on Orders $$5,0000.00++)
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Shipping:
FedEx Ground (Free on Orders $2,500.00 - $5,000.00)
Pricing for SARS-CoV-19 Antibody (Serology | Finger-stick) Test Kit | Assure Test
$ 75.00 per Kit | Minimum order 1 Cs (20 Kits per Cs): Price: $ 1,500.00
$ 50.00 per Kit | Minimum order 6 Cs (20 Kits per Cs): Price: $ 7,000.00
$ 35.00 per Kit | Minimum order 50+ Cs (20 Kits per Cs): Price: $ 35,000.00
