Quality Medical Inc.

Quality Medical Inc.
Your Medical Supply Solution!
Toll Free: 1-877-878-9882
E-mail: Quality Medical Inc.

Home	AED & Emergency O2	Bath & Shower Chairs	Beds	Blood Pressure
Canes	Cane & Crutch Tips	Cast Protectors	Commodes & Supplies	Crutches
Diabetes Supplies	Disinfectant & Sanitizers	Electrotherapy	Enteral Feeding	First Aid
Forearm Crutches	Grab Bars & Tub Bars	Incontinent Care	Mastectomy Supplies	Orthopedic
Ostomy Supplies	Quad Canes	Pain Management	Personal Hygiene	Respiratory
Rolling Walkers	Scooters	Walkers	Wheelchairs	Wound Care
	Order Form	Ordering & Shipping	Shopping Cart

Type in your Information, Then PRINT this Order Form on Your Printer
Quality Medical Inc. 3005 S. Idalia St., Aurora Colorado 80013 - Fax: 1-800-846-7609 (See Instructions)

Ship to (name):
Street Address:
City, State & Zip:
Phone Number: E-mail:

Credit Card : Master Card: Visa: Discover: American Express:

Card No.: - - - Expiration Date ( 00/00 ): /
Authorization No. on Back of Card (See Instructions) :

Name As It Appears On Card:
Billing Street Address:
Billing City, State & Zip:
Billing Phone Number:

Signature _____________________________________ Date ______________

SEND THIS FORM VIA FAX or MAIL ONLY!

INSTRUCTIONS: Copy down the information on the products you wish to purchase, including the SKU number. If you do not know the shipping cost, we can add it for you or Give us a Call. Type in the information above and Print this form to your printer using the print button. Fill out the form COMPLETELY.
Fax or Mail ( ONLY ) to us with a copy of your prescription if required. Upon receipt of this form we will E-mail you a confirmation of your order and any shipping charges that may apply.
Please provide your E-mail address.
We accept: Master Card, Visa, Discover, American Express, Checks*, Money Orders, and Wire Transfer's. Sorry No Cash Payments Accepted, and No COD's.
*Checks require a 3-5 day clearing period from the time we receive it, before your item will ship.
For Credit Card transactions, we ask that you give us your 3 digit Authorization Number, located on the back of your card for Master Card, Visa, Discover. The AMEX Card number is on the front of the card located top right ( 4 digits ). These authorization numbers verify that the credit card used for this transaction is in hand and limits fraudulent transactions.

Qty	Product Description - SKU Number	Price Each	Total


*Colorado residents, ADD 3.95 % Sales Tax
( If unknown we will add it for you, See Instructions ) SHIPPING
TAX + SHIPPING + PRODUCT SUBTOTALS => TOTAL