Standard Order Form - Precision Medical, Inc.

Order Submitted By:

Date:

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Name *

First

Last

Email *

Customer Contact Information

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Contact Name: *

First

Last

Contact Phone: *

Contact Email: *

Customer Company Information

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Customer Name:

Customer ID:

Customer Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Customer PO:

Reference PO:

Shipping Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Ship via:

Order Information

Quantity | Part Number | Unit Price

Item 1

DO NOT SUBMIT CREDIT CARD INFORMATION ON THIS FORM.

To submit credit card information:

Fax a Credit Card form to our secured fax line at 610-262-6533.
Include the PO number or WEB order number on the Credit Card form when faxing.

OR

Call Customer Service at 610-262-6090 to give the information over the phone.

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Accepted file formats: .jpg, .jpeg, .png, .pdf, .xls, .xlsx, .csv, .doc, .docx

Additional Notes

Paragraph Text

Order Submitted By:

Customer Contact Information

Customer Company Information

Order Information

Quantity | Part Number | Unit Price

DO NOT SUBMIT CREDIT CARD INFORMATION ON THIS FORM.

To submit credit card information:

Fax a Credit Card form to our secured fax line at 610-262-6533. Include the PO number or WEB order number on the Credit Card form when faxing.

OR

Call Customer Service at 610-262-6090 to give the information over the phone.

Additional Notes

Fax a Credit Card form to our secured fax line at 610-262-6533.
Include the PO number or WEB order number on the Credit Card form when faxing.