Physicians' Record Company

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 do not 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.

Quantity	Item Number	Item	Price
		Anniversary Pen
Health Information Management - 10th Edition OUT OF PRINT - NO LONGER AVAILABLE
		Health Insurance Claim Form
		UB-92 (Universal Billing Form)
		UB-04 (CMS-1450) Universal Billing Form
		Valuables Envelopes
	O-960	Erasable Neon Tab Dividers (10 sets per box)	$20.43/box
		Colored Border Laser Paper	$7.50/pkg.
		Colored Border Laser Paper	$7.50/pkg.
		Colored Border Laser Paper	$7.50/pkg.
		Colored Border Laser Paper	$7.50/pkg.
		Colored Border Laser Paper	$7.50/pkg.
		Delivery Room Register
		Emergency Room Register
		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:

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Facility Name: *

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Address: *

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

Phone: * Ext: Fax:

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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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