PED-Med Order Page

Order Page

Thank you for your interest in our products. Simply fill out the form below and click submit. Make sure that all required information is entered including your phone number, that way we can reach you if we require any information. If you would rather place an order directly you can do so by calling 1-800-724-4885. Items are shipped flat and dry.

Thank you for choosing a PED-Med Therapy Product.

We want to give the best service. It is helpful that you leave as much of your postal, telephone and e-mail address information in the body or signature of your message when contacting us. Thank you!

Sales Order Form

Buyer Information:

(Select the items that apply, and then submit the form. Required fields.*)

Buyer First Name	*
Buyer Last Name	*
Buyer Company
Buyer Box-Suite
Buyer Street	*
Buyer City	*
Buyer State
Buyer Zip	*
Buyer Country
Buyer Phone	*
Buyer FAX
Buyer E-Mail

Bill-To Information:

(Skip if same as buyer.)

Customer No	(If know, see old invoice.)
Bill To Name
Bill To Box-Suite
Bill To Street
Bill To City
Bill To State
Bill To Zip
Bill To Country
Bill To Contact Name
Bill To Phone
Bill To FAX

Ship-To Information:

(Skip if same as bill to.)

Ship To Name
Ship To Address1
Ship To Address2
Ship To Address3
Ship To Phone
Ship To FAX
Shipping Instructions

Order Information:

Customer PO No	*
Ship Via	*
Ship Date	*
Terms	*

Item Information:

1st Item

Item Number

Qty Ordered	*
Unit Price$	* (Does not include shipping or handling.)

2nd Item

Item Number

Qty Ordered
Unit Price$	(Does not include shipping or handling.)

3rd Item

Item Number

Qty Ordered
Unit Price$	(Does not include shipping or handling.)

Payment Information:

(Please select payment method. DO NOT enter credit information here! You will be contacted for it later.) Sales tax and shipping cost (please call for estimate) may be added to your order!

Check or Money Order Credit Card Bank or EFT

Questions?

(All orders must be acknowledged to be accepted. Print hard copies for your records.)

Rep Code

(Used by Sales Reps Only.)