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Tribute Marketing, Authorized USA Sales Representative for  Tel: 508-455-4646 Optional: Scan-to-PDF and email to: info@bloodleakalarm.com |
FAX THIS INQUIRY/ORDER FORM TO: 508-455-4647 Product: Redsense Hemodialysis Blood Leak Alarm Reliable Blood Loss Detection Upon Venous Needle Dislodgement. Sales Representative / Merchant Site: www.BloodLeakAlarm.com |
| Organization/Company Name | |
| Contact Person & Title/Position | |
| Contact Person Email | |
| Tel & Fax | Fax: |
| USA Shipping Address (Street) | |
| USA Shipping (City State Zip) | |
| How did you learn about Redsense? | __ Internet Search
__ Mail Piece
__www.BloodLeakAlarm.com Web Site Other: ________________________________________ |
| I am not ready to order yet. I have some questions. | __ Please have a
representative call me. The best time of day is ___________ Comments: |
| PRICING FOR LOWEST PER-TREATMENT COST | Unit Qty. | Tier | Price Per Unit | Total |
| Redsense Alarm Unit with NA Charger RA-1-RA001J | 1 - 11 units | $ 699.00 | ||
| Redsense Alarm Unit with NA Charger RA-1-RA001J | 12 + units | $ 599.00 | ||
| Redsense Sensor, Sterile (100 units/case) RS-1-RS001J-Z | 100-900 | $ 1.750 | ||
| Redsense Sensor, Sterile (100 units/case) RS-1-RS001J-Z | 1000-8900 | $ 1.690 | ||
| Redsense Docking/Charging Station (Holds 5 Units) | ||||
| Redsense Armbands (5-pack) | ||||
| Shipping via UPS Ground, FOB:
Bothell, Washington |
- - - - - - - - | - - - - - - - - - | To Be Determined | |
| Subtotal |
Payment Information: At this time, only faxed orders orders are accepted from medically licensed individuals and clinics for use in a clinical setting only.
| VISA MC DISC AMEX | __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ |
| Security Code on card's signature panel. | __ __ __ (3 digits) Amex (4 digits) __ __ __ __ |
| Name / Organization Shown on Card | |
| Billing address
for this Card (USA only) |
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| Authorized Signature for Card: | X_________________________________ Date ______ |
| Your Purchase Order # or Reference # |