Place Orders Online
This form is for existing customers.

Click here for easy order form to fax or mail.

Existing Customers
* Required fields

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

Terms:
>Bill Me >Credit Card on File

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

Last four numbers

>C.O.D.

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:
Message

Confirm Order By Fax:
>Yes >No

Fax Number


Order Form:
Qty Unit Catalog No. Desc./Optional Unit Price
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Sub-total: $
> Include 6% CT Sales tax: $
Total: $
PBS Med
Phone 1-800-727-8885
Fax 1-800-525-4568