Patient Order Form
MORELLE SOS SCAR TREATMENT ORDER
Print this form and fax it completed to 1-800-345-9767
Your Doctors Name : ______________
From:
Mr./Mrs./Ms. _____________________________ Delivery address if different
Address:________________________________Address:____________________________
City:___________________________________ City:_______________________________
State / Zip:______________________________ State / Zip:___________________________
Phone:(_____)-(______)-(________)........Fax:(_____)-(______)-(________)
| PRODUCTS | SIZE | NO. PER PACK | COST PER PACK | PACKS ORDERED | TOTAL VALUE |
| Morelle SOS | 5cm. x 5cm. | 2 | $40.00 | . | . |
| Morelle SOS | 10cm. x 10cm. | 1 | $65.00 | . | . |
| Morelle SOS | 10cm. x 20cm. | 1 | $85.00 | . | . |
| Morelle SOS | 10cm. x 30cm. | 1 | $125.00 | . | . |
| Morelle SOS Mamplast | Std. (20 cm.) | 1 Pair | $210.00 | . | . |
| Morelle SOS Mamplast | Ext. (30 cm.) | 1 Pair | $260.00 | . | . |
| Morelle SOS Abdoplast | 4 cm. x 45cm. | 1 | $125 | . | . |
| Morelle SOS Starter Pack | Various | 13 | $225.00 | . | . |
| Morelle SOS Round Block | . | 1 Pair | $125.00 | . | . | .
| S&H please add | USA $10.00 | Europe $25.00 | Others $60.00 |
(___).I have an account
(___).I do not have and account
(___).Please open an account for me
** Payment for non account clients is due before shipping
Please fax a copy of your check or money order with this form and put them both in the mail to us:
All Orders are shipped 2nd day air. We accept Credit Cards PLEASE CALL 1-888-345-9767
Morelle Medical Products Inc.
P. O. Box 4027
Queensbury, NY 12804
USA
Total Value of this Order $__________._Please find attached copy of check/money order for $_______.__
FOR CREDIT CARD ORDERS, PLEASE FILL IN BELOW:
Circle One: Visa / MasterCard
Credit Card Number________________________________________
Expiration Date____________________________________________
Signature for Authorization__________________________________
Print Name________________________________________________
Fax This Form to 1-973-786-0155 or Call the Order in on 1-973-328-1660