BEVACIZUMAB (AVASTIN®) ORDER FORM
Advanced Pharmacy RX Valet LLC, Greenville, SC Phone: 855-798-2538
Repackaged Avastin by Medivant Order (Select 1 Option Only)
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25 syringes ($54/Syringe)
50 syringes ($52/Syringe)
100 syringes ($45/Syringe)
200 syringes ($45/Syringe)
300 syringes ($45/Syringe)
400 syringes ($45/Syringe)
500 syringes ($45/Syringe)
600 syringes ($45/Syringe)
700 syringes ($45/Syringe)
800 syringes ($45/Syringe)
900 syringes ($45/Syringe)
1000 syringes ($43/Syringe)
Total Order Cost
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Total Order Cost
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PRODUCT SPECIFICATIONS
Pack Quantity: 5 syringes per clamshell
Presentation: Ompi Alba Glass Syringe
Concentration: 1.25mg/0.05ml
Fill Volume: NLT 0.07ml
Needles: TSK Low Dead Space 33g x 9mm
Storage: Refrigerated (2 - 8 degrees celsius)
FACILITY DETAILS
Facility Name
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Clinic NPI license #
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Facility Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Buyer Name
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First Name
Last Name
Primary Buyer Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Primary Buyer Contact Email
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example@example.com
Payment Option
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Pay via Credit/Debit Card
Buyer Notes
Authorized Signature
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Date
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Month
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Day
Year
Date
Submit
MackMatt Healthcare, an authorized agent
Del Mar, California, (209) 435-1513
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