Serene Breast Implant Collateral Order Form

Serene Breast Implant Physician Collateral Order Form
PLEASE NOTE: MUST BE A BIMINI HEALTH TECH CUSTOMER BEFORE ORDERING COLLATERAL. If you are not yet a BHT Customer, please fill out our New Customer Form to get started:

Bimini Health Tech New Customer Form

If you are already a Bimini customer, please proceed below. Thank you!
Please indicate how many packs of Patient Brochures or Size Charts you need. Brochures are packs of 25 (limit 5). Size charts are individual (limit 3). Brochure Holders are 1 per. Please email orders@biminihealthtech.com to order Implants or for any other needs or special quantity requests.
Collateral
prevnext( X )
Serene Breast Implant Patient BrochureQuantity indicates a pack of 25 brochures each.
$ Free Qty



Serene Breast Implant Patient Warranty CardQuantity indicates a pack of 25 cards each
$ Free Qty



Serene Breast Implant Size ChartSize chart for use during patient consult
$ Free Qty



Serene Implant Brochure HolderAcrylic brochure stand with Serene logo.
$ Free Qty
Physician Name*

First NameLast Name
Practice Name*
Office Phone Number
E-mail*
example@example.com
Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Special Delivery Instructions
Should be Empty:

Serene Breast Implant Physician Collateral Order Form