Page 1488 - Performance Health | Formerly Patterson Medical

Patterson Medical Order Form
Before you begin, please copy this order form to use again and again.
BILL TO:
Customer Account Number Customer Account Name Address
City
3 Method of Payment (Terms — Net 30 days): Check (Payable to Patterson Medical)
Bill our account: Purchase Order Number_____________________
1
Credit Card: Visa Card Account Number:
MasterCard Discover AmEx Expiration date____________
Phone ( Fax (
Your Name
) )
Name (Please Print)______________________________________________ Signature____________________________________________Date_______
Charges will not be processed until a shipment is made.
Credit Card Billing Address_______________________________________ City________________________ State_________________Zip__________
State
Zip
2 SHIP TO: (If different than bill to) Customer Name
Attention
Department
Street Address
City State
4 Product Selection
Zip
Shipping Charges
Standard parcel charges will apply to all ground shipments*†
and will be calculated at time of order. For non-credit card orders, please call customer service to obtain shipping charges.
* Additional charges may apply; please refer to ordering information provided in this catalog for complete details.
† NOTE: Due to escalating fuel surcharges from our freight carriers, we are now forced to pass on a fuel surcharge for all ground orders. We reserve the right to modify the surcharge as market conditions change.
QUANTITY
PRODUCT NUMBER
PRODUCT DESCRIPTION
PRICE EACH
TOTAL
1Every order must include applicable sales tax. If you are tax exempt, please fax your tax exemption certificate along with your order. If you are unsure about your sales tax, please contact customer service.
5 To Order: 1-800-323-5547
MERCHANDISE TOTAL SHIPPING & HANDLING
SUBTOTAL SALES TAx1 (on subtotal) TOTAL
Thank you for your order!
©2016 Patterson Medical
All rights reserved. Printed in USA.
Phone Fax
1-800-547-4333
Online
www.pattersonmedical.com
Mail To:
Patterson Medical
28100 Torch Parkway, Suite 700 Warrenville, IL 60555-3938