SOUTHEAST OXYGEN ORDER FORM

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Address:	1829 South Dixie Highway
	Pompano Beach
	Florida 33060

Phone:	USA:	800-650-5953
	INT:	954-941-1288
	FAX:	954-941-3380

STEP ONE: Please provide delivery information:

Full Name :

Phone:

Address:

E-mail Address:

Address 2:

City:

State:

Zip:

STEP TWO: Please provide payment information:

International orders require a wire transfer of US$ prior to shipping.

Card Type:

VISA _______ MasterCard _______

Card Number:

Expiration:

Month:_______ Year:_______

CCV # :

_______

Name on Card

Credit card billing information if different from above:

First:

Last:

Address:

City:

State:

Zip:

STEP THREE: Please indicate your order here:
Quantity	Product Description	Price Each	Total







Tax (as required for residents of Florida) 6%
Shipping
Order Total
Return fee of 25% on all returned merchandise. FDA regulations prohibit return of items marked for single-patient use. Shipping and handling fees are non-refundable.

STEP FOUR: Sign and fax this order form, along with REQUIRED PRESCRIPTIONS to: 954-941-3380. You may alternatively mail it to: Southeast Oxygen, 1829 South Dixie Highway, Pompano Beach, Florida 33060

I am the authorized signor for the above credit card and approve the above charges to be billed to my credit card.

Signed: ______________________________________________ Date: __________