Micromedics Product Order Form

Place an Order

Please fill out the below order form and submit it to our Customer Service Department. You will be contacted by a Customer Service Representative within 24 business hours to confirm your order. If you prefer to fax your order to Micromedics, please use our downloadable Order Form (PDF).

If you are a new customer and have not placed an order with Micromedics, please visit the Information for New Customers page. If you do not know if you have an existing account with Micromedics, please fill out the order form below and indicate in the comments text box that you do not know if you have an existing account.

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:*

Customer ID:

Bill to:

Name:*

Address:*

Address:

City:*

State:*

Zip:*

Country:*

Ship to: Use Billing Address

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 prepaid and added to invoice.

Ship Via:

Select Shipping Option*:	Other: Please indicate method	Shipping Account Number:
NOTE: Orders received after 3:00 PM CST will be shipped the next business day.

Comments/Questions:

Enter Above Security Code*:

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	Notice: Always read product labeling/inserts for complete instructions, warnings and restrictions! Instru-Safe, MicroWick, MicroWick ET, Spectrum Burs, RhinoCath, RhinoGuard, MicroEdge, DuraCision, Doyle Spacer Splint and FibriJet are trademarks of Micromedics Inc. © 2010 Micromedics, Inc. 800-624-5662 Contact Us