New Customers - U.S. Medical Professionals

Account Information

Company Name

Shipping Information

Contact Name

Email Address

Telephone Number

Website Address

Shipping Address

Line 1

Line 2

City

Postal Code

State/Province

Country

Billing Information

(Leave blank if same as Shipping Information)

Contact Name

Invoicing Email Address

Telephone Number

Billing Address

Street Address

Apt, Suite, Floor, etc.

City

State

Zip Code

Preferred Shipping Carrier

UPSFedExOther

Shipping Account #

Healthcare Category

Please select the type of healthcare facility you represent (check all that apply):

AudiologyCardiologyClinicEEGHospitalNeurologyPhysician’s OfficePsychiatry / CounselingUniversityOther:

Product Selection

Description

Item #

Retail Price

Quantity

Total

4 oz. Tubes (3-pack)

10-30

$27.30

x

=

25g Tubes (6-pack)

10-61

$17.25

x

=

25 g Tubes (20-pack)

10-65

$51.15

x

=

Weaver Co | NuPrep | Single-Use Cups

Single-Use Cups (24-pack)

10-91

$30.40

x

=

4 oz. Jars (3-pack)

10-20-4

$25.15

x

=

4 oz. Tubes (3-pack)

10-20-4T

$25.20

x

=

8 oz. Jars (3-pack)

10-20-8

$46.50

x

=

Weaver Co | Ten20 | Single-Use Cups

Single-Use Cups (24-pack)

10-20-1

$29.15

x

=

TOTAL

Important Notices:

Line item totals reflect retail pricing with volume discount breaks. If your company has arranged a different price structure, it will not be shown here.

TOTAL does not include shipping. Shipping charges will be added according to pre-arranged agreements.

Additional payment information

Additional shipping information

We can only ship product to authorized distributors, hospitals, or other medical organizations
Shipping charges will be prepaid and added to your invoice unless your company has a UPS, FedEx or other account to which shipping charges can be applied.
Unless otherwise requested, orders will ship via ground delivery.
Shipments to PO boxes and drop shipments can not be completed.