June Accessory order form (PDF)

AGCESSORY ORDER

28

Axon-II - Delta NCS SYstem

FORM

Effective June 2o'15

Handlinglncluded QuantitY

Hand-held Test Electrode & Gable
Ground Gable '
4"X4" Rubber Sponge Holder
Sponge (10 pack)

$ Total $

$225'00
125'oo
45.00
5O'OO

{5O'OO
Stick-on Potentiometer Electrodes ({OO pack) .
255'oo
Potentiometer Gable
455'OO
Heavy Duty Potentiometer Gable.
Textbook - Pain Fiber Etectrodiagnosis FREE www.lpain.com FREE
Waveform Upgrade Includes: Laptop computer w/ preloaded analysis, waveform
3,580.50
software, cables and foot-pedal . . Includes Excise Tax . .
125.00
on Waveform
One Year Extended
Axon-ll - Delta NGS Year Extended Warranty
Warranty Non-Transferable: Extended warranty includes use of the copyright protected

SUBTOTAL
GALIFORNIA DELIVERY - 8% SALES TAX
SUBTOTAL

UPS DELIVERY CHOICES

Ground (1"t item ${5.00 each additional item $5.00.
Next Day Air. . .T'l
Handling UPS Rates To Your Location Apply
2nd Day Air. . . . ' .

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GrandTotal..'.'

GHECK or MONEY ORDER
MAIL TO: PainDX, Inc.
25{4 TemPle Hills Drive
Laguna Beach, Ga 92651
PLEASE PRINT CLEARLY

Phone

Ship to
Name

Address

State

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Email

FAX

Phone
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GREDIT GARD

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PLEASE PRINT CLEARLY

Name on card:

Number:

Expiration:

Month

Year

Card Billing Address:
Signed:

FAX To: (800) 875-01 19

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