Product Order Form

Date:

PO Number:

Ship To:

Practice/Hospital Name

C/O:

Address

Phone Number

Bill To:

Practice/Hospital Name

Contact

Address

Phone Number

Distributor Information

Distributor Name

Sales Rep Name

Phone Number

Email Address

Order Details

Product Code

Description

Quantity

Price

Total Quantity

Total Price

613034700

613034701

613034702

613034705

613034706

613034708

C Scope Kit 10 Pack

C Scope Kit 2 Pack

C Scope Kit 5 Pack

C Scope Handpiece

C Scope Tablet

C Scope Handpiece/Tablet Complete Pkg

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.
FM19001-3, Rev. 02

Product Order Form

Date:

PO Number:

Ship To:

Bill To:

Distributor Information

Order Details

Product Code

Description

Quantity

Price

613034700

613034701

613034702

613034705

613034706

613034708

C Scope Kit 10 Pack

C Scope Kit 2 Pack

C Scope Kit 5 Pack

C Scope Handpiece

C Scope Tablet

C Scope Handpiece/Tablet Complete Pkg

This information/document is confidential and proprietary. It may not be reproduced, used or disclosed to others without written consent of CIT Ortho. FM19001-3, Rev. 02

This information/document is confidential and proprietary. It may not be reproduced, used or disclosed to others without written consent of CIT Ortho.
FM19001-3, Rev. 02