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: Fax:E-mail: BILLING INFORMATION:Cat.
2 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. 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.
3 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
