Mobile: (804) 690-3475
Office: (804) 755-8701
Fax: (804) 755-8711
E-Mail: sales@imagingconcepts.com

Imaging Concepts' Imaging Supply Order Form

#1

What would you like to order?

Qty U/M Part Number Description Price Ext

#2

Cust. ID if known



Customer Number

#3

P.O. Number (If required)

Purchase Order Number

#4

Current customers include only account name. If multiple ship to addresses, include street address for each ship to location.

Bill To Address

Ship To Address

#5

Who do we call with questions regarding this order?





Contact Name


Practice Name

#6

What number and what email address would we use with questions regarding this order?

Phone Number

Email Address

#7

How would you like your odrer shipped?













Shipping Instructions

Please only check one.

[Freight charges will be added to your invoice]

UPS Ground
UPS Blue (2 Day)
UPS Orange (3 Day)
UPS Red (Overnight)
Other please specify

#8

How would you like to pay?

Payment Terms

BILL ME (net 30 days existing customers)
CHARGE TO CREDIT CARD

#9









Submit this form