Ramesh Lift Fixation Order Form

Ramesh Lift Fixation Order Form

Caution: Federal law restricts this device to sale by or on the order of a physician
Surgeon Name*

First NameLast Name
Email
example@example.com
Facility Name*
- Select Product and Quantity Below:*
  prevnext( X )
  
  4595$250.00
  Ramesh Lift Fixation 3 Per Package 2.9mm x 6.25mm x 0.75mm
  
  Quantity
  
  RML2.8$185.00
  Drill Bit 2.8mm with 6mm Drill Stop: Medical-grade stainless Steel, universal fit for straight handpiece, cleaning and sterilization instructions included.
  
  Quantity
  
  Subtotal $0.00Shipping $0.00Total $0.00
- Shipping Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Is the billing / invoice address the same as the shipping address?*
  
  YesNo
- Invoice Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Should be Empty: