Kylon® Fabric Devices and Spirabrush CX®
ORDER FORM
CUSTOMER AND SHIPPING INFORMATION
Date:
PO #:
Customer / Company Name:
Person Ordering:
Referred by:
Phone #:
Email:
Ship to address:
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ZIP:
Product will ship via FedEx - To receive tracking notification, please fill in information for the person receiving the product
Receiving Person Name:
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Shipping Continental US: $15.00 per box (up to 250 units per box), Shipping California Customers only: $10.00 per box
All Orders: $5.00 Handling Charge Per Box (up to 250 units per box), Alaska, Hawaii, Puerto Rico - call for rates
PICTURE
NAME / SKU
DESCRIPTION
LIST PRICE PER UNIT
QUANTITY
Exocervical Tissue Sampler
$5.75 each
Endocervical Curette Tissue Sampler
$5.75 each
Endocervical Curette Tissue Sampler (for short, shallow, or stenotic cervix)
$5.75 each
Prices shown are list, if requested quantities qualify for volume discounts, the volume based pricing will be included on the final invoice
PICTURE
NAME / SKU
DESCRIPTION
LIST PRICE PER UNIT
QUANTITY
Cervical Biopsy Device
$6.75 each
Prices shown are list, if requested quantities qualify for volume discounts, the volume based pricing will be included on the final invoice
PAYMENT INFORMATION
ORDER SUBMISSION / PRODUCT SUPPORT
