Mail To: Luvmedical - PO Box 61048 - Lafayette, LA 70596 or Fax: (888) 262-0839
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Date       PO Number        
(if applicable)
Full Name          
Billing Address         Shipping Address
City           City              
State     Zip Code     State     Zip Code        
Item Number Description Size Qty Cost Ext .Cost
Circle Payment Method     Subtotal            $    
  Check      Money Order     * Processing Fee          $    
  Visa         Master Card     AMEX       Promotional Discount Code:
  Card Nos.:         
  Expiration Date:                Tax (LA residents add 9.5%)     $    
  Card Security Code:   * * Shipping & Handling      $    
    Total (USD$)    
Submit a Fax Number or your Email Address to receive your Order Confirmation
* $100 Minimal Order Requirement. If subtotal is less than the MOR, please add an additional $10.00 to order.
* * To calculate shipping & handling, multiply order subtotal by .15 and add $4.00 handling fee to that amount.
     If order will be shipped to a residential address, please add a $3.60 carrier surcharge to shipping.
Buyer Signature X