Page 2 - Hensler-Assure ALL DMS Rapid Testing Billing and Purchasing Packet RV1
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Distributed & Marketed by:
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
