Micromedics Product Order Form

Place an Order > Information for New Customers

Welcome to Micromedics! To place your order please completely fill out the form below and hit the “Submit Form” button. A Customer Service Representative will contact you within 24 business hours to confirm your order and provide you with a Customer ID. Thank you for placing your order with Micromedics.

If you prefer to fax your order to Micromedics, please use our downloadable Order Form (PDF).

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:*

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:

How did you hear about Micromedics?

Comments/Questions:

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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