In the dialog box below, please list product
desired, number of boxes, purchase order
number, and special instructions such as a
specific delivery date.

Your Name:

Use this box to
specify your
request:

Business Name:

Your E-mail Address:

Your Phone Number:

orderform2.pdf

Click on the Order
Form2.PDF link above
to view a printable
order form that you
can fax to us.  You
must have Acrobat
reader software on
your computer.

Address:

Prices:

1-box(30 tubing sets) Smartset-001.4 -$297







1-box(50 Adaptors) MR Smartset adaptor-001.3- $225






1-box(15 tubing sets) Smartset w/sideport-001.2- $210

City/State/Zip:

Purchase Order
Number

Billing Address: (if different from shipping)

The SmartTourniquet-002.0 $480
Price includes two each Thigh
Cuff, Extension tubing,
and Manometer, as well as 5
Smartsets.  (pictured below)

Your Name:

Business Name:

Your E-mail Address:

Your Phone Number:

Address:

City/State/Zip: