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Order Form

Click here for a more printer-friendly order-form.

Name: ___________________________________________

Address: _________________________________________

_________________________________________________
(no PO Boxes please)

Email: ____________________________________________

City: ___________ State: ___________ Zip: ____________

Telephone: _______________________________________

Credit Card Orders — Fill in boxes with card number

                                       

Expiration Date: Month __________ Year __________

Visa Mastercard American Express Check or Money Order

Minimum Order $10.00

OFFICE USE ONLY ITEM QUANTITY PRICE TOTAL
         
         
         
         
         
         
         
         
         
         
POSTAGE AND HANDLING: No COD’s
$10.00 - $16.00 .......... $9.00
$16.01 - $23.00 .......... $10.00
$23.01 - $30.00 .......... $11.00
$30.01 - $74.99 .......... $12.00
Over $75.00 .......... FREE SHIPPING
SUBTOTAL:  
Postage & Handling:  
TOTAL:  

Print this form, fill in your order, and mail, fax, or call in your order to:

OAKHURST COMPANY
3000 Hempstead Turnpike Suite 302
Levittown, New York 11756-1338
PHONE (800) 831-1135 FAX (516) 731-5607

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Happy doctors & patients
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