Order Please use the form below to help you place the order. Order If you are human, leave this field blank. BILLING INFORMATION Practice Name * Name * First and Last Name Address * City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Email * Phone * Billing=Shipping Shipping Address is different SHIPPING INFORMATION Practice Name Attention: First and Last Name Adress City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code DETERMINING YOUR NEEDS Room Identifier e.g. 1 # of Devices 1-4 5-8 Extra DSM? Yes No Add Room Remove Room MODULES Module Device Control Module Quantity Price Subtotal DSM Label Device Selector Module DSMQty DSMPrice DSMSubtotal FPM Label Foot Pedal Module FPMQty FPMPrice FPMSubtotal ACCESSORIES Item for DSM (100 per pack) Quantity Quantity-100/package. Max 20 packs per order Price Subtotal BatteriesLabel for DSM BatteryQuantity (1/room recommended). Max 20 per order BatteryPrice BatterySubtotal SpareDCMLabel Device Control Module SpareDCMQuantity SpareDCMPrice SpareDCMSubtotal SpareDSMLabel Device Selector Module SpareDSMQuantity SpareDSMPrice SpareDSMSubtotal SpareFPMLabel Foot Pedal Module SpareFPMQuantity SpareFPMPrice SpareFPMSubtotal Order Totals Subtotals Subtotal Promotional Code Discount Amount Total Less Discount MI Sales Tax Shipping & Handling Grand Total Terms and Conditions * I Agree to the Terms and Conditions Return Authorization Code
