Tribute Marketing, Authorized USA
SalesTel: 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? | __ Web Search
__ Mail Piece
__www.BloodLeakAlarm.com Web Site |
| I have some questions. | __ Please have a
representative call me. The best time of day is ________ |
| PRICING FOR LOWEST PER-TREATMENT COST | Unit Qty. | Tier | Price Per Unit | Total |
| Redsense Alarm Unit with NA Charger RA-1-RA001-C (Clinical use) | 1 - 11 units | $ 393.00 | ||
| Redsense Alarm Unit with NA Charger RA-1-RA001-C (Clinical use) | 12 + units | $ 314.00 | ||
| Redsense Alarm 5-Alarm Pkg. w/Charger RA-1-RA001-H (Clinical) | 1 - 2 units | $ 1964.00 | ||
| Redsense Alarm 5-Alarm Pkg. w/Charger RA-1-RA001-H (Clinical) | 3+ units | $ 1570.00 | ||
| Redsense Alarm Unit with NA Charger RA-1-RA002-C (Home/Self Use) | 1 - 11 units | $ 393.00 | ||
| Redsense Alarm Unit with NA Charger RA-1-RA002-C (Home/Self Use) | 12+ units | $ 314.00 | ||
| Redsense Sensor Patch, Sterile (100 units/case) RS-1-RS001-Z | 100-900 | $ 2.320 | ||
| Redsense Sensor Patch, Sterile (100 units/case) RS-1-RS001-Z | 1000-8900 | $ 2.260 | ||
| Redsense Sensor Patch, Sterile (100 units/case) RS-1-RS001-Z | 9000+ | $ 2.1560 | ||
| Redsense Multi-Charger NA # RC-1-RC001-M | 1 | 97.00 | ||
| 5 Velcro strap S (small) #RV-5-RV001 | 1 | 18.50 | ||
| 5 Velcro strap M (medium) #RV-5-RV002 | 1 | 19.50 | ||
| 5 Velcro strap L (largel) #RV-5-RV003 | 1 | 20.40 | _______________ | |
| Shipping via UPS Ground, FOB:
Bothell, Washington |
Approx. | 8.00 | ||
| Price as Published by Manufacturer: June 8, 2011 | Total |
Payment Information: At this time, only faxed orders orders are accepted from medically licensed individuals and clinics for use in a clinical setting only. Please note: Freight is not included in the above prices but is paid by the customer Shipping charge – 8USD per shipping box .Payment terms – 30 Days. For credit card payments – a credit card fee of 3.5% will be added.
| VISA MC DISC DINERS | __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ |
| Security Code on card's signature panel. | __ __ __ (3 digits) Expiration Date __________ (MM/YY) |
| Name / Organization Shown on Card | |
| Billing address
for this Card (USA only) |
|
| Authorized Signature for Card: | X_________________________________ Date ______ |
| Your Purchase Order # or Reference # |