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 Order Form


• Send your order in online using the form below, or...

• Print this .PDF document and fax it to (407) 897-0851, or mail it to ErgoMed Products.

• If you'd rather contact us by phone, call us Toll free: (800) 350-6948.


    *Required Fields.
*Name:  
*Email Address:  
*Phone Number:  
Fax Number:  
     
Facility Name:  
Shipping Address:  
City, State, Zip:  
     
Billing Address:
(If different than shipping) 		 
City, State, Zip:  
     
Payment Type:
(Check or Money Order)		  
P.O. #:
(If necessary)		  
     

    Ordering Information:    
         
  1)
         
  2)
         
  3)
         
  4)
         
   

Comments:


Shipping Charges:
Orders shipped via U.S. Mail

1 Sling..... Add $11.00
2 Slings..... Add $13.00
3 Slings..... Add $14.50
4 Slings..... Add $16.00
5 Slings..... Add $17.50
6 Slings..... Add $19.00
For each additional
Sling add $2.00

 
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  ©2013 ErgoMed Products, Inc.
Phone: 800.350.6948
Fax: 407.897.0851


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Ergomed's products are not approved, endorsed or associated in any way with Arjo Huntleigh Getinge Group ("Arjo").