PPE Order Form ALL

Full Name *

First Name Last Name

Practice Name *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Contact Number *

Area Code Phone Number

E-mail *

Member Name *

Is shipping address same as billing address? *

Yes No

Shipping Address (USPS Format)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

1. Disposable Surgical Face Mask: 50 Piece Box (Certification CE/FDA)

2. KN95 Face Mask: 10 Piece Box (Certification CE/FDA)

3. Disposable Isolation Medical Gown | Certification CE/FDA

4. Protective Medical Isolation Gown Clothing Overalls | Certification CE/FDA

5. 75% Alcohol Wet Wipes | 200 per box | Certification CE/FDA

6. Thermometer Temperature Gun - Non Contact | Certification CE/FDA

7. Digital Thermometer | Medical Infrared Thermometer | Certification CE/FDA

8. Safety Face Shield | Certification CE/FDA

9. Safety Medical Goggles | Certification CE/FDA

10. Safety Medical Goggles WIDE

11a. Disposable Latex Rubber Gloves SMALL (100 piece per box) | Certification CE/FDA

11b. Disposable Latex Rubber Gloves Medium (100 piece per box) | Certification CE/FDA

11c. Disposable Latex Rubber Gloves Large (100 piece per box) | Certification CE/FDA

11d. Disposable Latex Rubber Gloves XLARGE (100 piece per box) | Certification CE/FDA

12. Disposable Medical Shoe Covers 100pc/bag | Certification CE/FDA

13. Disposable Surgical Hat Cap |100 per bag | Certification CE/FDA

14. Cotton Mask - 10 per box | USA Made

15. Face Shields with Foam Headband | 3M Material - USA Made

16. Hand Sanitizer 8 oz (250ml) 24 in a case

17.

18. Gallon Hand Sanitizer

19. CaviWipes

PLEASE READ BELOW AND ACCEPT BEFORE YOU PLACE YOUR ORDER:

Our medical society is extremely pleased to be able to offer this service to our members. All of our supplies are in our warehouse and ready to ship immediately once your order and payment is received.

If you order multiple products from our stock pile, each product will ship separately. Our shipping rates are $9 per box.

The invoice for your purchase will include shipping, warehouse, handling fees and a credit card processing fee. All fees have been applied at our costs only.

Your order will only be released once payment has been received.

Please acknowledge that you understand and accept the above statement regarding your order of the PPE Supplies. *

YES, I understand

Email address to send the payment url link *

example@example.com

Society *