|
Universal
Medical Technologies Inc.
ORDER FORM
Print, Complete and
Fax to (623)670-7723 |
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List
Price
Per Case
($ US)
|
Number
of
Cases |
SubTotal
per Line Item
|
| INFUSION
PUMPS |
|
|
Specify Language & Power
Types
eq:IP-##-X
see How to
Order |
|
| UA-11016 |
Eureka-IP
Pump
Battery, AC Adapter/ReCharger, Manual & Carry Pack |
|
765.00
|
|
|
| UA-11017 |
Eureka-LF
Pump
Battery, AC Adapter/ReCharger, Manual & Carry Pack |
|
765.00
|
|
|
Tubing
Administration Sets for Eureka-IP
|
UA-11051
|
50
ml/hr, 1.2ug Air Elim Filter
|
25
Sets per Case
|
150.00
|
|
|
UA-11101
|
100
ml/hr, 1.2ug Air Elim Filter |
25
Sets per Case |
150.00
|
|
|
UA-11201
|
200
ml/hr, 1.2ug Air Elim Filter |
25
Sets per Case |
150.00
|
|
|
Tubing
Administration Set for Eureka-LF
|
UA-11001
|
1 ml/hr, 1.2ug Air Elim Filter |
25
Sets per Case |
200.00
|
|
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UA-11002
|
2 ml/hr, 1.2ug Air Elim Filter |
25
Sets per Case |
200.00
|
|
|
UA-11005
|
5 ml/hr, 1.2ug Air Elim Filter |
25
Sets per Case |
200.00
|
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Item
Subtotal
|
|
|
Discount
Amount
(See Chart for # of Case Items)
|
|
|
SubTotal
(Item SubTotal less Discounts)
|
|
Accesories
|
UA-11023
|
Carry
Pack (Shoulder/Waist) for Eureka IP/LF
|
|
15.00
|
|
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UA-11021
|
Battery
Pack
|
|
20.00
|
|
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UA-11039
|
IP/LF
Pole Mount for Eureka IP/LF |
|
50.00
|
|
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UA-11022
|
ReCharger/Power
Supply for Eureka IP/LF (US) B Type
|
|
35.00
|
|
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UA-11036
|
ReCharger/Power
Supply for Eureka IP/LF (UK) G Type |
|
35.00
|
|
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UA-11037
|
ReCharger/Power
Supply for Eureka IP/LF (EU) E Type
|
|
35.00 |
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Grand Total
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Ordered
By:
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Contact Information
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Account #:
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Signature:
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