Date:

PO Number:

Bill To:

Practice/Hospital Name

Contact

Address

Phone Number

Distributor Information

Distributor Name

Sales Rep Name

Inventory Source

Phone Number

Email Address

Procedure Information

Procedure Type

Date of Procedure

Physician Name

Delivered Order Form

Order Details

Product Code

Description

Quantity

Price

613034700

C Scope Kit 10 Pack

613034701

C Scope Kit 2 Pack

613034702

C Scope Kit 5 Pack

613034705

C Scope Handpiece

613034706

C Scope Tablet

613034708

C Scope Handpiece/Tablet Complete Pkg

Total Price

Customer Signature (Printed)

Customer Signature

Sales Rep Signature (Printed)

Sales Rep Signature

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This information/document is confidential and proprietary. It may not be reproduced, used or disclosed to others without written consent of CIT Ortho.
FM19001-2, Rev. 02