Autoclave / Sterilizer / Parts / Accessories Order Form

Medical
 Your Sterilizer and Autoclave Experts                                    Home

Alfa Medical  59 Madison Ave, Hempstead, NY 11550
[email protected]    1-800-762-1586    fax 516-489-9364

How to order:
        1. Print this page (click on the printer icon)
        2. Fill in the form
        3. Fax to 801-838-4341

Last name ________________First___________________Company (if applicable)_______________________

Address_________________________________________________________________

City____________________________State_____________________ Zip_____________

Tel #__________________Fax#_________________Email_________

What kind of sterilizer do you have now?__________________________
Please circle type of practice :
DDS - MD - DVM - Tattoo - Body Piercer - Lab - Hospital - Dealer - Nursing Home - Other (specify)
 
 
Part #
Quantity
Description
Cost
 Sub total
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* Frieght -  For North America,  Specify [  ] Priority overnight 
   or [  ] regular ground. 
* International parts friegt $65.00.
*  email to [email protected] if you need Exact frieght cost. 		   Frieght _________________ 

Total cost _______________

Please sign _______________________________________________
 
MC [   ] VISA [   ] Amex [   ] Discover [   ]

  card #_______________________________________ exp ____/____
 Please write here the 800 # of the bank which is on the back of the credit card -   1-800-______-_______

 You may also wire the money to N. Fork Bank ABA 021407912 acct# 6124005502