Physicians' Record Company

3000 S. Ridgeland Avenue

Berwyn, IL 60402

800-323-9268

fax: 708-749-0171

Order Form

If ordering an item not listed, fill in item number, description, and price if known. New customers please enter Visa, MasterCard or American Express below. Current customers must enter account number and purchase order number (if used). If you don't enter your account number and purchase order number, your order may be delayed. Prices shown do not include shipping and handling charges or tax (where applicable). Prices are subject to change without notice. Click here for our fax order form. Please be sure to enter a quantity.

PRICES SUBJECT TO CHANGE WITHOUT NOTICE

Quantity	Item Number	Item	Price

		Health Insurance Claim Form
		UB-04 (CMS-1450) Universal Billing Form
		Valuables Envelopes
		Chart Dividers
	O-960	Erasable Neon Tab Dividers (10 sets per box)	$20.43/box
		Colored Border Laser Paper	$8.05/pkg.
		Colored Border Laser Paper	$8.05/pkg.
		Colored Border Laser Paper	$8.05/pkg.
		Colored Border Laser Paper	$8.05/pkg.
		Colored Border Laser Paper	$8.05/pkg.
	If custom, provide book number:	Delivery Room Register
	If custom, provide book number:	Emergency Room Register
	If custom, provide book number:	Register of Operations/Operating Room Record



	Other:
	Other:
	Other:

BILLING INFORMATION:

New Customer (Please enter your credit card information below.)

Current Customer - Please enter your 7 digit account number:

Verification Code: Expiration Date:

Online Credit Card Information and Personal Information is not maintained online nor is your credit card information kept in an online database. Credit card orders are not processed online. Each credit card order is processed manually by our Customer Service Department.

Purchase Order Number:
(Please note: For billing purposes if you are placing an order for a custom item and a stock item at the same time, we require separate purchase order numbers for the custom items and the stock items.)

BILLING ADDRESS:

Facility Name: *

Contact Person: *

Address: *

City: * State: * Zip Code: * Country: *

Phone: * Ext: Fax: E-Mail: *

Select shipping method: Other:

SHIPPING ADDRESS (if different):

Facility Name:

Attention:

Address:

City: State: Zip Code: Country:

Comments:

How would you like your confirmation of this order sent?

(To avoid duplicate orders, please do not click the 'Submit' button more than once.)

Terms - NET 30

No returns after 30 days

Must call for Return Authorization (1-800-323-9268 ext: 39)

15 % restocking charge on authorized returns - 25 % on unauthorized

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