Print this form to order by mail. Or call our toll free order line at   1-877-203-1210.
Ship To: Bill To: (If Different)
First Name:
Last Name:
E-mail:
Phone:
Company:
Address:
City:
State:
Zip Code:
Country:
First Name:
Last Name:
E-mail:
Phone:
Company:
Address:
City:
State:
Zip Code:
Country:
Credit Card Information (if applicable)
Card Number: Card Type:(visa,mc,amex)
Name On Card: Expiration Date:
Product
Code		 Size/
Color		 Item Description Number
Ordered		 Price
Each		 Total
Price

You can print this form and then fill it out by
hand, or you can type in the boxes and print the
form already filled out. If you need room for
more items, just list them on a second copy of
this form and fill in the "total from page 2" box.

Fill in the credit card information, or enclose
a check or money order made out to
Renaissance Medical Supply and mail to:
Renaissance Medical Supply
PO Box 51236, Idaho Falls, ID, 83405.
Or Fax to: 208-528-8078.
For help call toll free 877-203-1210.

     Total from page 2:
Sub Total:
ID residents add 6% SALES TAX:
Shipping and handling:
Total:
Thank you for your order!
Home Page  www.rmsmedical.com