MEDICAL/DENTAL SEATING SYSTEM

ORDER FORM

 

Part #

Description

Qty

Unit Cost

Subtotal

 

1005408

Cushion Set; MC 400/450/550
Color:_____________________________________

 

225.00

  

 

1005393

Cushion Set; CPC 3000
Color:_____________________________________

 

225.00

  

411124

MC 400 Mechanism

 

190.00

  

1032337

MC Upper Structure w/o Cushion

 

360.00

  

412033

Small Base w/ Castors; 400/450

 

155.00

  

412197

Large Base w/ Castors; 500

 

165.00

  

412286

Height Cylinder; MC 400 (short)

 

85.00

  

412097

Height Cylinder; MC 450 (medium)

 

85.00

  

410789

Height Cylinder; MC 550 (tall)

 

90.00

  

411889

Seat Adjustment Cylinder 400-N / 420-N

 

65.00

  

411888

Back Adjustment Cylinder 700-N / 720-N

 

65.00

  

411077

Hard Floor Castors, #62 (set of 5)

 

30.00

  

411071

Carpet Floor Castors, #61 (set of 5)

 

30.00

  

411578

Foot Ring; MC 550

 

180.00

  

411017

Plastic Covers (elbow)

 

25.00

  

411017

Telescoping Sleeve

 

25.00

  

411063

Backrest Cover, outer shell only

 

40.00

  
410735 Seat Cover, outer shell only   45.00  

 

Left Hand Body Arm or Right Hand Body Arm

 

265.00

 
 

Order Total:

 

Shipping:

 

Total:

 
Name: Telephone #:                                           Fax #:
Address:

 

Method of Payment:
__  Visa
__  MasterCard
__  C.O.D.
Credit Card #:
Signature: Expiration Date:
Please fill out the form and then return the form to us via fax or mail.  Fax to: #(901) 683-6745
When your order is received you will receive a copy to confirm the items.  This confirmation will include the S & H charges, the total amount of charges for the order and the shipping date.
All orders will ship via UPS Ground unless otherwise specified.  Prices subject to Change without notice.  Revised October 2004.

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