Transcription of ORDER FORM - Bio-Tissue, Inc.
1 For orders placed 8 AM - 4 PM ESTCall: (888) 296-8858 Fax: (305) 412-4429 For orders placed 4 PM - 7 PM ESTCall: (800) 990-1306 Fax: (858) 676-0331 Prices effective February 20, 2014 ORDER INFORMATION: Fees are per INTERNAL USE ONLY:SHIPPING INFORMATION:Facility/Hospital Name: Shipping Contact Name:Date of Surgery (MM/DD/YY): Product Arrival Date (MM/DD/YY): Shipping Address:City: State: Zip:Phone: Fax:E-mail: Facility/Hospital Name: Billing Contact Name:Billing Address:City: State: Zip:Phone.
2 Fax:E-mail: BILLING INFORMATION:Cat. FeesAG-1510 FAmnioGraft x cm$560AG-2015 FAmnioGraft x cm$670AG-2520 FAmnioGraft x cm$770AG-3535 FAmnioGraft x cm$895AG-5050 FAmnioGraft x cm (for Stevens-Johnson syndrome patients)$1395 AGD-1075 AmnioGuard x cm (for glaucoma shunt tube covering)$385PK-16 PROKERA Biologic Corneal Bandage$949 PKSPROKERA SLIM Biologic Corneal Bandage$949 PKPPROKERA PLUS Biologic Corneal Bandage$1049 Total FeesShipping & Handling Charges*Total ORDER FeesIt is recommended that all products be stocked and stored or ordered for delivery at least two days prior to use to avoid any unforseen shipping delays.
3 R. N. C. F. N. Purchase ORDER Number: Bio-Tissue Account Number: Credit Card Payment: Credit card payment options are available. A complete account application form must be on INFORMATIONDOMESTIC ( ) SHIPPING & HANDLING OPTIONS*:Overnight Delivery (by 10:30 am) Add $ Overnight (by 8:30 am) Add $ Delivery Add $ Day Shipments (call for charges)International Shipping & Handling Options (call for charges)*Please select one of the following shipping options.
4 Shipping prices and methods are subject to availability. Bio-Tissue will not be responsible for delays due to carrier delivery or processing by customs POLICY: Bio-Tissue will send a same size replacement for EXPIRED tissue if it is stored using product stroage guidelines. No credits will be issued. Call 1-888-296-8858 for more FORM8305 NW 27 Street, Suite 101, Doral, FL 33122 Toll Free: (888) 296-8858 | Fax: (305) 412-4429 E-mail: | International: +001 (305) 412-4430 Website: REV K 01/15
