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|
Gorge Medical Order Form |
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| To
place an order, please print this form and mail it with your check to: |
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| Gorge
Medical |
| 902
12th Street |
| Hood
River, Oregon 97031 |
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| If you
would like to use a purchase order, or have any questions regarding your order,
please call us at 800-354-8044, between 9:30 am and 5:00 pm, Monday - Friday,
Pacific time. |
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| Billing Information |
Ship-to Information (leave
blank if same as billing) |
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|
| Name:________________________________ |
Name:________________________________ |
| Address:______________________________ |
Address:______________________________ |
| City:______________
State_____ Zip_______ |
City:_______________
State_____ Zip______ |
| Phone:________________________________ |
Phone:________________________________ |
| Email:________________________________ |
Email:________________________________ |
| Purchase
Order #:______________________ |
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|
| Description |
Unit
Price |
Quantity |
Sub-Total |
|
|
|
|
| Durkan CTS
Gauge |
$225.00 |
________ |
$________ |
| Adjustable
2-Pointer |
$49.00 |
________ |
$________ |
| WEST-handtm
System |
$225.00 |
________ |
$________ |
"Hands-On" Hand Evaluation Kit
|
$645.00
+$29 shipping |
________ |
$________ |
Durkan Hand Surgery Frame
|
$200.00 |
________ |
$________ |
Additional Hand Straps
Set of 3
|
$75.00 |
________ |
$________ |
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| Domestic
Shipping Costs: |
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| Our prices include the
shipping costs to all destinations within the US, except for the "Hands On"
Evaluation Kit which is $29 extra. |
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| International
Shipping Costs |
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| Please call for shipping
charges to International destinations. 800-354-8044 |
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|
Thank you
for your order. Please allow 2 - 4 weeks for delivery. |
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