Summit Medical | Shippert Medical Technologies

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Place an Order - New Customers

Please fill out the below order form and submit it to our Customer Service Department. If you prefer to fax your order to Summit Medical, please use our downloadable Order Form (PDF).

The information you provide is used only to process your order.

Terms and Conditions

Fields marked with an asterisk (*) are required.

If you'd like to browse our site or submit your order at a later time, chose "Save Order".

Date:
P.O. Number:
Contact Name:*
Department:
Facility/Company:*
 
Phone Number:*
Fax Number:
E-mail:*
 



Bill to:
Contact Name:*
Facility/Company Name:*
Address:*
Address:
City:*
State:* 
Zip:* 
Country:*



Ship to:
Use Billing Address
Contact Name:*
Facility/Company Name:*
Address:*
Address:
City:*
State:* 
Zip:* 
Country:*


Product Number* Qty* Description Price Sub Total
$ $
$ $
$ $
$ $
$ $
$ $
$ $
†All quantities are in boxes. Order Total:
$
Please note: shipping and handling is prepaid and added to invoice.



Ship Via:

Select Shipping Option*:
Other:

Please indicate method
Shipping Account Number:
NOTE: Orders received after 2:00 PM CST will be shipped the next business day.

Comments/Questions:

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