Page 16 - Hensler Surgical - Biosciences COVID Rapid Testing Proposal - Facility_Clinic_Hospital - 5_6_2020
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Distributed & Marketed by:
13825 N Northsight Boulevard, Suite 101
Scottsdale, AZ 85260
Phone +1 480-207-1884
Fax +1 480 207-1863
New Client Information
SHIPPING INFORMATION
Company/Facility/Hospital
Contact Name
Title
Contact Phone
Address
Suite / Building
City / State / Zip
Fax #
Email
BILLING INFORMATION BioLab Sciences Accepts Credit Cards or ACH Withdrawals
Billing Desired Circle one: Credit Card (No Fee) ACH Withdrawal (No Fee)
Directions:
1. Credit Card and or ACH Withdrawal Forms Attached
2. Please complete the appropriate payment for Credit Card or ACH
3. Fax completed New Client Inform ation Form and paym ent form to +1 480 207-1863
