Place Orders Online

This form is for existing customers.

Click here for easy order form to fax or mail.

Existing Customers
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Billing Information:
Customer Number
*Billing Name
*Contact Name
*Phone Number
Purchase Order No.

Bill Me

Credit Card on File

If more than one card on file,
Please enter last 4 numbers
of correct card.

Last four numbers


Shipping Information:
Ship to Address on File Multiple Ship
to Customers

Ship To Address

Ship Via:
UPS Ground US Priority Mail Other (see below)

Special Instructions & Messages:

Confirm Order By Fax:
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Fax Number

Order Form:
Qty Unit Catalog No. Desc./Optional Unit Price

Sub-total: $
Include 6% CT Sales tax: $
Total: $

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your OB/GYN equipment and supplies.

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OB/GYN Patient