Allied Multicare Center



ACCESSORY REORDER FORM

Name and address: Purchase Order Number:

Date of order: ________________________

____________________________________ Phone number:

Fax number:

|PRODUCT DISCRIPTION |MODEL NUMBER |LIST PRICE |QUANTITY |TOTAL PRICE |

|Duotrode Electrodes |7 Pkg of 17 electrodes (22 Tests) |$74.00/box | | |

|Huggables Electrodes |Case of 600 electrodes (120 tests) |$175.00/case | | |

|Huggables Electrodes |Box of 30 electrodes (6 tests) |$15.00/box | | |

|Electrode Harness |EH-1 (VAT) |$295.00/harness | | |

|Electrode Harness |EH-2 (ENG) |$295.00/harness | | |

|USB Serial Adapter |CC-USB-SER |$150.00/ adapter | | |

|Prep & Stay |Prep & Stay (3400-15) |$12.00/bottle | | |

|Signa Gel |Signa Gel for electrodes (15-25) |$15.00/tube | | |

|Tape Measure |72” round tape measure (inch and metric) (84029) |$7.00/ tape measure | | |

|Surgical Tape |1”x10yards. 12 rolls/box (1538-1) |$24.00/box | | |

| | | | | |

|Alcohol Prep Pads |2 ½”x1 ¼” pads 200 pads / box (B60307) |$11.00/box | | |

|Surgical Scissors |4 ½” Steel Surgical Scissors (48006M) |$11.00/each | | |

|Gauze Squares |2x2 12 ply gauze pads 100/box (3381) |$18.00/box | | |

|Surgical Caps |Disposable Caps 100/box |$30.00/ box | | |

|Power Cord |10’ UL approved hospital grade power cord |$30.00/each | | |

| |(115078CD) | | | |

|Head Strap |Hs-004 |$95.00/each | | |

|VAT and ENG Test Administrator’s |John Coverstone |$225.00/manual | | |

|Manual | | | | |

|Extension Cable for VAT/ENG |QV-90k9 |$38.00 | | |

|Power Supply |PS-100 |$285.00 | | |

Revised: 04-07-2015 Form 5000 V.1

Ordering Options

1) Email order forms to: sales@

2) Fax Order forms: 951-302-2976

3) online store

Shipping prices will vary, depending on weight and destination of package. Orders submitted before 3pm PST will be shipped that day. Orders submitted without a shipping method selected will go out UPS Ground.

SHIPPING: UPS Overnight ? 2nd Day ? 3rd Day ? Ground ?

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WSR

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