Page 3 - Hensler-Assure ALL DMS Rapid Testing Billing and Purchasing Packet RV1
P. 3
2019-nCoV IgG/IgM Rapid Test Cassette
Order Form
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
ALFA Scientific CoV-19 Test Kit
Spring Healthcare CoV-19 Test Kit
Total:
Shipping Method
FedEx: Pick Up
Date to Receive: Time to Receive: Date of Pick Up:
Ship to Address: Time of Pick Up:
Address 2: By:
City:
State: Zip:
Notes:
Healthcare Provider to Read Tests: (Must Fill in Below)
F FeeddEExx NNeexxtt DDaayy 1100::3300 ( (FFrreeee oonn OOrrddeerrss $$55,,000000..0000++))
Shipping:
FedEx Ground (Free on Orders $2,500.00 - $5,000.00)
Pricing for SARS-CoV-19 Antibody (Serology | Finger-stick) Test Kit
$ 50.00 per Kit | Minimum order 1 Cs (20 Kits per Cs): Price: $ 1,000.00
$ 40.00 per Kit | Minimum order 6 Cs (20 Kits per Cs): Price: $ 4,800.00
$ 35.00 per Kit | Minimum order 50+ Cs (20 Kits per Cs): Price: $ 35,000.00
