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.

Please Note: If you have never placed an order with us before, your first order must be paid for prior to the product shipping. After we have an "order history" with you (at least one order), we will be able to get you set up with terms.

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 - 5:00 pm EST
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

Returns & Cancellation Policy

Returns Policy

(800)876-8143 - [email protected] - 10 Glenlake Pkwy Ste 130 Atlanta, GA 30328
Office Hours: Monday - Friday 9:00am to 5:00pm EST

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