Phone:	1-780-963-0754
Fax:	1-780-963-5428
Email:	eickemeyerveterinary@telus.net

FAX ORDER FORM Please Print order form and fax to 1-780-963-5428

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 $10.00 shipping fee

_____________________________________________________

Signature

__________________________________

Date