Chiropractic ProScribe
(TM)
Forms Order Sheet
Please Fax to 952-891-4003
SHIP TO: (please print clearly)
| Clinic Name | Date | ||
| Address | Doctor | ||
| Phone | |||
| Contact |
| QUANTITY | ITEM# | DESCRIPTION | UNIT PRICE | PRICE |
|
|
CRV-0050 |
50 Cervical Exam Forms |
$12.50 |
|
|
|
DLYN-0250 |
250 Daily Notes Forms (2 exams per form) |
$32.00 |
|
|
|
DX-0050 |
50 Diagnosis Forms |
$12.50 |
|
|
|
DX2-0050 |
50 Diagnosis Forms (new for 7.0) |
$12.50 |
|
|
|
GEN-0050 |
50 General Exam Forms |
$12.50 |
|
|
|
HIS-0050 |
50 History Forms (pages 1-2,3-4,5-6) |
$37.50 |
|
|
|
INS-0050 |
50 Insurance Response Forms |
$12.50 |
|
|
|
LUM-0050 |
50 Lumbar Exam Forms |
$12.50 |
|
|
|
LWX-0050 |
50 Lower Extremity Exam Forms(2 sheets) |
$25.00 |
|
|
|
NAR-0050 |
50 Narrative Forms |
$12.50 |
|
|
|
RAD-0050 |
50 Radiographic Forms |
$12.50 |
|
|
|
REF-0050 |
50 Referral Forms |
$12.50 |
|
|
|
THR-0050 |
50 Thoracic Exam Forms |
$12.50 |
|
|
|
PLN-0050 |
50 Treatment Plan Forms |
$12.50 |
|
|
|
UPX-0050 |
50 Upper Extremity Exam Forms (2 sheets) |
$25.00 |
|
|
|
OSW-0050 |
50 Revised Oswestry Forms (2 per form) |
$12.50 |
|
|
|
ROL-0050 |
50 Roland-Morris Forms (2 per form) |
$12.50 |
|
|
|
NEC-0050 |
50 Neck Disability Forms (2 per form) |
$12.50 |
|
|
|
GPA-0050 |
50 General Pain Disability (2 per form) |
$12.50 |
|
|
|
SUBTOTAL |
|
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|
|
Sales Tax (MN Only) |
|
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|
|
Shipping Charges |
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|
|
TOTAL |
|
Rates subject to change without notice. Effective May
2004. All sales are final. Unopened form packets may be returned for
exchanges only.
(c) 2004, Trillium Technology