Purchase Order Form

If you are ready to submit a purchase order, please fill out the form below. Please include a phone number where we can reach you if additional information is needed to process your order.

Company/Hospital/Clinic

Purchaser Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Purchase Order Number

Item ID and Quantity

Preferred email for confirmations

Shipping Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Method

Shipping Payment

Prepay & Add

Collect

Shipper Account Number (for collect)

Does this location have a loading dock

Yes

Special shipping instructions.

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred email for invoicing

Comments

United States

Klarity Medical Products USA
600 Industrial Parkway
Heath, Ohio 43056
Peter M. Larson, President

T (877) 599-8905 (toll free)
T (740) 788-8107
F (740) 788-8109
E sales@klaritymedical.com
W www.klaritymedical.com

China

Klarity Medical & Equipment (GZ) Co., Ltd.
No. 14, 3rd Street Shawan, GETDD
Guangzhou 510730, China
Daren Zhan, President

T +86 (20) 8222-6380
F +86 (20) 8208-8552
E lucy@klarity-medical.com
W www.klarity-medical.com

PO

Purchase Order Form

United States

China