| Date:* |
Practice Name:* |
| Technician Name:* |
Phone Number: |
| Shipping Address:* |
| City, State, Zip Code:* |
| Image |
Item Description/Number
|
Unit
|
Rate
|
Qty
|
Amount
|
 |
Diopsys Disposable Electrode
(6015-0002-01) |
300/Box
|
$79.75
|
|
|
 |
Diopsys Disposable Electrode
(6015-0002-02) |
600/Box
|
$159.50
|
|
|
 |
Lead wire Set 48" (3 wires)
(6015-0003-00) |
1 Set
|
$21.95
|
|
|
 |
Gold Cup Electrodes 48" (3 wires)
(6015-0005-00) |
1 Set
|
$49.80
|
|
|
 |
NuPrep EEG Skin Prepping Gel, 4 oz tubes
(6010-0001-01) |
3 Tubes
|
$23.75
|
|
|
 |
Ten20 Conductive EEG Paste, 4 oz tubes
(6010-0002-01) |
3 Tubes
|
$18.65
|
|
|
 |
Ten20 Conductive EEG Paste, 8 oz jar
(6010-0003-00) |
3 Jars
|
$34.75
|
|
|
 |
Thermal Printer Paper, 2 ¼" x 85' roll
(6012-0002-00) |
1 Roll
|
$2.00
|
|
|
 |
Prep-Check Electrode Impedance Meter
(6014-0001-01) |
1 Meter
|
$450.00
|
|
|
 |
Pirate Patch, 2 ½"Eye Patch w/elastic string
(6013-0001-01) |
144/Bag
|
$23.00
|
|
|
 |
Diopsys® Sticker Eye Patch – BLUE TEDDY BEAR
(6013-0002-00) |
250/Roll
|
$40.00
|
|
|
 |
Diopsys® Sticker Eye Patch – PURPLE BUTTERFLY
(6013-0002-01) |
250/Roll
|
$40.00
|
|
|
 |
Enfant® Patient Brochure "A new way to protect your child's vision"
(5669-0000-00) |
50/pack
|
$6.80
|
|
|
 |
Enfant® Folleto Paciente "Una nueva forma de proteger la vista de los niños"
(5669-0000-01) |
50/pack
|
$6.80
|
|
|
 |
Diopsys® NOVA Patient Brochure "A Window into the Visual Brain"
(5669-0000-02) |
50/pack
|
$6.80
|
|
|
 |
Enfant® 36" Repositionable Wall Mount Ruler
(5669-0050-00) |
1
|
$15.00
|
|
|
 |
Diopsys® NOVA 39" Repositionable Wall Mount Ruler
(5669-0050-01) |
1
|
$15.00
|
|
|
 |
Enfant® Customized Promotional Postcards*
(5669-0001-00)
*Call for pricing of additional quantities |
500
|
$114.75
|
|
|
|
1000
|
$124.75
|
|
|
|
2000
|
$187.50
|
|
|
|
*When ordering Customized Postcards, please
provide an email address where Practice Name,
Physician Name, and Contact Information can be verified.
Email:
|
Total**
|
|
|
**Sales Tax and Shipping/Handling Charges will be billed accordingly. Please expect 4-5 days for delivery.
|
| Method of Payment (please check one box): |
| Please bill me. Check made payable to Diopsys. Inc.(due upon receipt of invoice) I will phone in to pay by credit card. (973-244-0622) |
| PO Number: |
| :Typing your name above in the name field is the same as signing your signature and is legally binding. Please check the box that you have read this statement. |
|
