Client Supply Order Form
Order Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Order Type
Delivery
Pick-Up
Client's Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Office/Clinic/Hospital Name
Department
Delivery Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please enter the number of supplies you want per product/item:
Rows
Quantity
Price ($)
Total
Alcohol
Cervical Spatula
Cervical Brush
Bag Ziploc
Bag for Frozen Sample
Bag for Room Temperature Sample
Bag for Hazardous Sample
Sputum Container
Urine Container
Stool Container
Blood Sample Kit
Swab kit
Meconium/Umbilical Kit
Breath Test Kit
Urea Breath Test Kit
Formalin
Torniquet
Needles
Syringes
Shipping Box
Total Amount ($)
Payment Method
Credit Card
Check
Wire Transfer
Bank Transfer
PayPal
Remarks/Special instructions
REMINDERS
We'll contact you within 24-48 hours to confirm your order.
Kindly review the autoresponder email that you receive to make sure that the order is correct.
It is recommended not to order supplies for more than 30 days because of the temperature.
These supplies will be delivered or picked-up using boxes.
If you have any questions, please contact us at (123) 1234567 or email us at orders@abcsupply.com.
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