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IMPLANT order Form_7-21-08

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IMPLANT order Form_7-21-08 Powered By Docstoc
					                                                                                                   ORDER
 IMPLANTS: 1st MPJ Hemi & Met Head, Lesser Hemi & Met Head, TOV Sublalar

PO No:                                                 Patient:
Date Required:                                         Physician:

Bill to:                                                  Ship To:




Enter Quantity in box on left of style number. All Vilex Products are Cannulated
 Qty           Product#               1st PMJ "CHI" Hemi Implant                      Material     Price Ea.
           CHI-1C             Hemi Implant, #1, 15x13                              Cobalt Chrome
           CHI-2C             Hemi Implant, #2, 17x15                              Cobalt Chrome
           CHI-3C             Hemi Implant #3, 19x17                               Cobalt Chrome
           CHI-4C             Hemi Implant #4, 22x19                               Cobalt Chrome
           CHI-5C             Hemi Implant #5, 24x21                               Cobalt Chrome
           CHI-1T             Hemi Implant, #1, 15x13, Blue                          Titanium
           CHI-2T             Hemi Implant, #2, 17x15, Gold                          Titanium
           CHI-3T             Hemi Implant #3, 19x17, Magenta                        Titanium
           CHI-4T             Hemi Implant #4, 22x19, Green                          Titanium
           CHI-5T             Hemi Implant #5, 24x21, Bronze                         Titanium
           K113-16S           Hemi Guide Wire 113x1.6                                Stainless
 Qty           Product#               1st MPJ "Met Head Implant"                      Material     Price Ea.
           CMHI-14            Large Met Head Implant 14                            Cobalt Chrome
           CMHI-16            Large Met Head Implant 16                            Cobalt Chrome
           CMHI-18            Large Met Head Implant 18                            Cobalt Chrome
           CMHI-20            Large Met Head Implant 120                           Cobalt Chrome
           CMHI-22            Large Met Head Implant 22                            Cobalt Chrome
           K113-16S           Guide Wire 113x1.6                                     Stainless
 Qty           Product#          Mini "Lesser PMJ Hemi" CHI Implant                   Material     Price Ea.
           MCHI-09            CHI, Mini 09 Blue                                      Titanium
           MCHI-10            CHI, Mini 10 Gold                                      Titanium
           MCHI-11            CHI, Mini 11 Magenta                                   Titanium
           MCHI-12            CHI, Mini 12 Green                                     Titanium
           MCHI-13            CHI, Mini 13 Bronze                                    Titanium
           K100-11S           Guide Wire 100x1.1                                     Stainless
 Qty           Product#          Mini "Lesser MPJ Met Head" Implant                   Material     Price Ea.
           MMCI-09            Mini "Lesser" Met Head, 09                           Cobalt Chrome
           MMCI-10            Mini "Lesser" Met Head, 10                           Cobalt Chrome
           MMCI-11            Mini "Lesser" Met Head, 11                           Cobalt Chrome
           MMCI-12            Mini "Lesser" Met Head, 12                           Cobalt Chrome
           MMCI-13            Mini "Lesser" Met Head, 13                           Cobalt Chrome
           K100-11S           Guide wire 100x1.1                                     Stainless
 Qty           Product#           TOV Subtalar Arthroereisis Implant                  Material     Price Ea.
           TOV1-08            TOV Subtalar Implant #1, 8mm, Blue                     Titanium
           TOV2-09            TOV Subtalar Implant #1, 8mm, Gold                     Titanium
           TOV3-10            TOV Subtalar Implant #1, 8mm, Magenta                  Titanium
           TOV4-11            TOV Subtalar Implant #1, 8mm, Green                    Titanium
           TOV5-12            TOV Subtalar Implant #1, 8mm, Bronze                   Titanium
           K300-20            Guide wire 300x2.0                                     Stainless
Phone: 1-800-521-5002   Fax: 1-866-606-4911   Email: VilexInfo@blomand.net

				
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