AllHeart.com - The Largest Online Store for Medical Professionals Complete Form and Fax or Mail to:
AllHeart
3016 W. Georgia Street
Louisiana, MO 63353
fax: (660) 263-1239

Bill To: Ship To:
Name:   Name:  
Address:   Address:  
City:   State:   Zip:   City:   State:   Zip:  
Phone:   Phone:  
e-mail address (needed for order/shipping confirmation):  

item # color size qty. item description price each total price
             
             
             
             
             
             
Satisfaction Guaranteed!
WIf you're not completely satisfied with any merchandise you have received, just return it within 30 days of receipt for a full refund or exchange. (Some exceptions apply.) 		Shipping & Handling (see chart below):                    
Order Subtotal:                    
Sales Tax - California Residents Add 8.25%:                            
Missouri Residents Add 7.725%:                            
Virginia Residents Add 5.00%:                            
Gift Certificate Number:                                                                 Subtract Gift Cert. Value:                    
Internal Code: Fax or Mail                                                                 Your Order Total Due:                    

Shipping Method (check one)       __ U.S.A.       __ International
U.S.A.
Order Amount
$0.00 to $14.99 =
$15.00 to $25.99 =
$26.00 to $49.99 =
$50.00 to $74.99 =
$75.00 to $99.99 =
$100.00 to $199.99 =
$200.00 to $499.99 =
$500.00 to 749.99 =
$750.00 to 999.99 =
$1000.00 to 1999.99 =
$2000.00 to 2999.99 =
$3000.00 to 3999.99 =
$4000.00 to 4999.99 =
$5000.00 & up = 		U.S.A.
Ground Rate
$7.49
$8.49
$10.49
$12.49
$13.49
$15.49
$18.49
$19.99
$29.99
$59.99
$99.99
$139.99
$179.99
$199.99
U.S.A. Premium Ground Rate
$9.78
$10.78
$12.78
$14.78
$15.78
$17.78
$20.78
$22.28
$32.28
$62.28
$102.28
$142.28
$182.28
$202.28
U.S.A.
2-Day Air Rate
$14.49
$15.49
$17.49
$19.49
$20.49
$22.49
$25.49
$39.99
$59.99
$79.99
$159.99
$239.99
$319.99
$399.99
International
Order Amount
$0.00 to $14.99 =
$15.00 to $49.99 =
$50.00 to $99.99 =
$100.00 to $149.99 =
$150.00 to $199.99 =
$200.00 to $349.99 =
$350.00 to $499.99 =
$500.00 to $999.99 =
$1000.00 up = 		International
Shipping Rate
$22.49 (+ $10 per item)
$31.49 (+ $10 per item)
$34.49 (+ $10 per item)
$41.49 (+ $10 per item)
$45.49 (+ $10 per item)
$61.49 (+ $10 per item)
$68.49 (+ $10 per item)
$75.49 (+ $10 per item)
$96.49 (+ $10 per item)

Payment Method. Sorry, no CODs. (check one)
__Check or Money Order (Payable to AllHeart)     __Visa     __Mastercard     __American Express     __Discover
Print Name on Credit Card:  
Credit Card Number:                                                       CID: Expiration Date:  
Signature:   Today's date:  

Please Note: Checks must be drawn from U.S. banks.
©2009 Scrubs AC, Inc. - AllHeart.com®