LUVMEDICAL - PO Box 622, Youngsville, LA 70592 | Fax 800-547-6964 | info@luvmedical.com
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Date       PO Number        
(if applicable)
Company          
     
Your Name          
Phone          
Bill To Address         Ship To Address
                           
                           
City           City              
State     Zip Code     State     Zip Code        
Item Number Description   Size   Qty   Price   Ext. Price
           
           
           
           
           
           
Circle Payment Method     Subtotal            $    
  Check      Money Order     * Processing Fee          $    
  Visa        MasterCard     AMEX     Discover     Discount Promo Code, if any:
  Card #:         
  Expiration Date (MO/YR):                 Sales Tax (LA add 9.5%)   $    
  CVV Nos.:   * * Shipping & Handling      $    
     Total $    
Submit fax number or an e-mail to receive your Order Confirmation.
             
* $100 Minimal Order Requirement (MRO). If subtotal is less than the MOR, add $10.00 processing fee.
* * To calculate shipping & handling, multiply your order Subtotal Amount by 0.15
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