Place an Order Offline | Vasectomy Order Form

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Place an Order Offline | Vasectomy Order Form | The Vasectomy Store

Order Form

P.O. Box 630414
Little Neck, NY 11363 USA
Tel: 1-800-635-2452
Fax : 718 352 2984
E-mail: sales@vasectomystore.com

Customer Information

Physician or Representative:

Practice/Clinic/Org Name:

Street Address:

City, State, Zip:

Country:

Phone:

Fax:

Email address:

Payment Method

Check (made payable to Advanced Meditech International)

Please bill me* - Net 30
*(Existing accounts or satisfactory D&B rated firms, universities, & government agencies only)
If using a PO #, please fill out this order form.
Visa Master Card American Express

Card number:

CVV Code:

Expiration date:

Signature:

Items Ordered

Add Item
Item #	Qty.	Description	Unit Value	Total Value

Subtotal:
In New York Only, Add 8.875% State Sales Tax:
$14.00 Ground Shipping: International Orders Add $47.50 More
ORDER TOTAL:

In most cases, we ship less than 24 hours after receiving your order with payment. Shipment to AK & HI via FedEx add $47.50; to International destinations via International Express Mail (for a charge of $69.00). If you have special shipping needs or requirements, please contact our order department to make alternative arrangements. Please note that the shipping rate is based on product weight. For most International destinations, standard shipping on items up to 1 kilograms is via USPS International Express Mail for $59.00 USD. Over 1 kilograms, shipping will be at actual cost.

Comments or Special Instructions