The Phipps & Bird Portable Dialysate Warmer TM

for Continuous Ambulatory Peritoneal Dialysis Patients


This is NOT an electronic form. Because of credit card security we have created a printable form only. Please print out the form below, fill in the following fields, and either fax or mail it to Phipps & Bird. Thank you.

 


1519 Summit Avenue,
Richmond, Virginia 23230
Phone: 804-254-2737
or toll free: 800-955-7621 (USA)
Fax: 804-254-2955


( * ) Please fill in all required fields.


 

* Name:

   

 

* Company:

   

 

* Address:

   

 

* City:

   

 

* State:

   

 

* Zip Code:

   

 

* Country:

   

 

* Phone:

   

Price: $429 + ____________ (5.3% VA Sales Tax) = ____________ (Total)

 

Color Choice: Navy

   

Payment Method (check one):

Check or Money Order. Enclose check or money order, made payable to Phipps & Bird, for $429 (Virginia residents add 5.3% state sales tax). Shipping charges are included (Continental U.S.A. only).

 

Credit Card. (check one): VISA MasterCard American Express

 

   

* Card Holder's Name (please print):

   

 

* Card Holder's Signature:

   

 

* Credit Card Number:

   

 

* Expiration Date:

   
   

If you know someone who would like to order the P&B Portable Dialysate Warmer, please feel free to print off and give them a copy of this order form, or call us at 1-800-955-7621 for additional brochures and forms.

 

All orders delivered in 2 to 3 weeks.
 

Call Toll-Free (800) 955-7621 in Virginia (804) 254-2737

Fax - (804) 254-2955

Email - info@phippsbird.com


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 Phipps & Bird, Inc.