Artelon Product Request Form

PO Number
Case Date *
Distributorship *
Rep Name *
Customer Name *
Customer Phone Number

Area Code Phone Number
Customer Fax Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Representative Email
example@example.com
Account Email (if you want a copy sent to your account)
example@example.com
Patient Initials:
Do not provide Full Name
Physician: *
Product Label(s) with Serial Number
Serial Number *
Procedure
Receiving Signature *

Clear
Restock *

Bill Only Bill & Restock Sales Rep Bill & Restock Distributor Bill & Restock Accoun