Instruction manual

Order Form
REMOVE PAGE ALONG DASHED LINE TO FAX ORDER FORM
✁
Order Form
SHIP TO ORDERED BY
NAME NAME
DAYTIME PHONE DAYTIME PHONE
STREET ADDRESS
(CANNOT DELIVER TO P.O. BOX)
EMAIL ADDRESS
(OPTIONAL)
CITY/STATE/ZIP
PATIENT NAME
(IF DIFFERENT FROM ABOVE)
COUNTRY (IF OTHER THAN U.S.)
MAYO CLINIC PATIENT ID #
(IF APPLICABLE)
PRODUCT INFORMATION
ITEM # PRODUCT DESCRIPTION SIZE PRICE EACH* QTY TOTAL
*PRICES ARE SUBJECT TO CHANGE WITHOUT NOTICE. PRODUCTS AND SERVICES NOT AVAILABLE AT ALL LOCATIONS.
SHIPPING AND HANDLING (CONTINENTAL U.S.)
ORDERS TOTALING UP TO $125 WILL HAVE A FLAT $9.95 SHIPPING CHARGE (BULK ITEMS EXTRA). ORDERS OF MORE THAN $125 WILL BE SHIPPED FREE OF CHARGE. WE CAN
PROVIDE PREMIUM SHIPPING SERVICES INCLUDING NEXT DAY AND SECOND DAY. CHARGES FOR PREMIUM SHIPPING SERVICES WILL BE ADDED TO THE INVOICE. INTERNATIONAL
ORDERS WILL BE CHARGED ACCORDING TO THE DESTINATION.
METHOD OF PAYMENT
❑ CHECK OR MONEY ORDER ENCLOSED (MAKE PAYABLE TO MAYO CLINIC STORE)
❑ CHARGE (SELECT CARD TYPE BELOW)
❑ VISA ❑ MASTERCARD ❑ AMERICAN EXPRESS ❑ DISCOVER
CREDIT CARD NUMBER EXPIRES
SIGNATURE
❑ PLEASE CHECK IF YOU WOULD LIKE US TO FILE YOUR MEDICARE CLAIM.
PRICE TOTALS
SUBTOTAL $
TAX (IF APPLICABLE)
TAXES MAY VARY PER STATE
$
SHIPPING
(IF APPLICABLE)
$
TOTAL $
ORDER TOLL-FREE: 888-303-9354
FAX YOUR ORDER: 507-284-1272
MAYO CLINIC STORE
21 2ND STREET SW, SUITE 1-50
ROCHESTER, MN 55902
Order Toll-Free 888-303-9354 • Fax [phone] • Prices in blue are generally not covered by insurance
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