Phone:

  1-519-273-5558

Fax:

  1-519-271-7114

Email:

  edbukala@gmail.com

FAX ORDER FORM   Please Print order form and fax to 1-519-271-7114

CLINIC INFORMATION

*required

Name __________________________________________

Phone* __________________________________________

Clinic Name* _____________________________________

Fax* ____________________________________________

Address* ________________________________________

Email __________________________________________

Address 2 _______________________________________

Customer No ___________________________________

City* _____________________________________________

Province* ______________ Postal Code* _____________

 

CODE

DESCRIPTION

PRICE

QTY

TOTAL

EXTENSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GRAND TOTAL

All orders under $150 are subject to a $15.00 shipping fee

 

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Signature

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Date