Please fax this purchase
request form to: +1 (201) 670-0782

 
 
Personal data

Name:      Phone:
First Last

Cellular:   E-Mail:

Address:   
Number,Street City


State/Region Country Postal Code

Mailing address (if different from above):


Number,Street City


State/Region Country Postal Code

 
Purchase Order

Quantity:

 

Please send me _____units of the RESPeRATE at a price fo $350 per unit.

Shipping and Handling cost of: $15 for U.S. Orders. Additional charges may apply for international orders.
Recipient will pay taxes and customs if applicable.

 

Payment:

 

Credit Card type   MC   Visa   AE

           
Credit Card #
  
Valid through

Seven digits at the back of the card (on MC only):      

Check () I, hereby confirm the payment transaction via my credit card with the above data.



Signature Date (dd/mm/yy)

 
MEDICAL SERVICE OPTIONS, INC.
9-10 SADDLE RIVER RD. • FAIR LAWN • NJ 07410 • USA
TEL +1 (201) 670-9999 • FAX +1 (201) 670-0782 • WWW.MSOBIZ.COM