|
|
 |
|
Print, fill out, and mail to:
Wise Choice Nursing Consultants, LLC
3077 Country Lane Eugene, Oregon 97401 phone (541) 683-8528
NAME______________________________________________ ADDRESS___________________________________________ __________________________________________________
PHONE _______________________
_____Individual (2 1/2"x7") 1 pen OR 2 vials @ $23.00
_____Small (5 1/2"x6") 2 cartridge cards OR 3 vials @ $27.00
_____Duo-Pen (3 1/4"x7") 2 pens+2 cart OR 1 pen+vial @$29.00
_____Large (5 1/2"x7 1/2")1 pen+3 cart OR 4 vials OR 5 disp pens @ $30.00
_____X-Large (6"x8 1/2") 8 pens OR 10 cart OR 8 vials @ $36.00
_____Pump wallet (MiniMed or Disitron size)@ $30.00
_____Frio Vitesse carrying case (no cooling wallet) @$30
_____Headbands @ $9.00
_____Wristbands @ $11.00 Anklebands @ $14.00
_____Drink coolers @ $11.00
$5.00 shipping and handling
_____Check here if color choice is mine from stock available. Black or blue always available. ____________________________other color preference. If not available, may I substitute with stock on hand? _____ If NO and choice is NOT available, shipping may be delayed from a few days to three weeks. Is that acceptable? _____
Make check to WISE CHOICE NURSING CONSULTANTS, LLC
Credit card information: _____Visa ____M/C
Name ______________________________ Exp. date______
Number_____________________________
Security code back of card________
|
|
|
|
|
