Your Medical Store Purchase Orders Form

B2B Customers Wanting to Submit a Purchase Order

We are more than happy to provide your organization with an invoice for you to make payment via either a paper check or for an online order to be entered using a credit card. By completing this form, we will send you an invoice for the product requested to the email address you provide below.

SECTION 1: Purchasing Agent/Business Information

* Indicates required field

Are you a: *

Government Entity Business (includes clinics) Non-Profit Organization

Purchase Order Number *

Terms Requested - For New Customers *

Organization Name *

Purchasers Name *

First

Last

Type of Payment - For New Customers *

Card number to be kept on file Card will be used at time of payment due date Check mailed to AR/AP offices

Purchasers Email *

Purchasers Phone Number *

SECTION 2: Product Details

Product Needing to Order *

QUANTITY *

Use if more than one product is needed for ordering *

QUANTITY *

Use if more than two products are needed for ordering *

QUANTITY *

SECTION 3: Your Patient/Customers Information

Patients Name *

Patients Ship-To Address *

Patients Phone Number *

Any special delivery requests? *

Additional Comments *

Submit

ALL ORDERS OVER $100 SHIP FREE - LOWER 48 STATES
Alaska, hawaii, us territories & international customers
additional shipping charges calculated at checkout

Accepting All Major Credit Card Payments - Safe Secure Checkout with Stripe Payment Processing or PayPal

Secure Payment Processor

Now Accepting All HSA & FSA Cards

Protected

Questions? Chat with a Real Live Human (No Robots - Ever)
Get Fast, Reliable, Responses to your product questions!
Click the Live Chat Logo on the bottom, righthand side of your screen!
Monday - Friday 9:00 am - 7:00 pm East Coast
Communications Center is Closed on the Weekends
10 Glenlake Parkway, South Tower Suite 130, Atlanta, GA 30328

You may also send us your questions via email: [email protected]

US Shipping Policy

Order Cancellation Policy

Returns & Cancellation Policy

Returns Policy

(800)876-8143 - [email protected] - 10 Glenlake Pkwy Ste 130 Atlanta, GA 30328

Your Medical Store Purchase Orders Form

B2B Customers Wanting to Submit a Purchase Order

ALL ORDERS OVER $100 SHIP FREE - LOWER 48 STATESAlaska, hawaii, us territories & international customers​additional shipping charges calculated at checkout

ALL ORDERS OVER $100 SHIP FREE - LOWER 48 STATES
Alaska, hawaii, us territories & international customers
additional shipping charges calculated at checkout