Artelon Product Request Form

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

Area CodePhone Number
Customer Fax Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / 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 OnlyBill & Restock Sales RepBill & Restock DistributorBill & Restock Accoun