Mail In Order Form

To order by mail simply print this page and fill out all required information.

 

Make checks and money orders payable to Alpha Medical L.L.C. and mail your order to:

Alpha Medical L.L.C.

303 Church St

Rock Hill, SC 29730

 

Order form:

 

Bill To:___________________________________      Ship To:  ___________________________________

              ___________________________________                        ___________________________________

              ___________________________________                        ___________________________________

 

Item # Size      Color      Left / Right  Quantity Price Each Total    
             
             
             
             
             

Total

  

Payment type:

 


Check   Money Order     Credit Card
 

Card Type :   Visa    /    Master Card    /    Discover    /    AMEXPayment method:

Card Number: ___________________________________

Exp. Date: _____/_____/20_____       CVC No. __________

Signature_______________________________________