Medical Products Direct Fax or Mail-In Order Form

Print out this form, fill it out completely. If you are using a credit card you can fax it to 1-405-670-0957,
shipping charges will be added to the order later. If you prefer to send a check or money order please call
our customer service department Toll Free at 1-800-804-9549 and we will give you the total amount for
your order including shipping charges. Alternatively you can e-mail http://lib1.store.vip.sc5.yahoo.com/lib/medicalproductsdirect/support@medicalproductsdirect.com
for a shipping amount or run a "fake" order through the website to see what the shipping charges would be
and cancel the order before you are required to put your credit card information in. Be sure to include the
items that you wish to purchase and your state and zip code on the shipping amount request.

Mail completed form to:

Name Brands Direct Inc.
Dba: MedicalProductsDirect.com
3945 S.E. 15th Street, #200
Del City, OK 73115
Ship to Address:

Name:


Address:


City, State and Zip

Phone Number:

Ship to Address:
Name:
Address:
City, State and Zip
Phone Number:

Check this box if billing address is the same as the shipping address.
Bill to Address:

Name:


Address:


City, State and Zip

Phone Number:

Bill to Address:
Name:
Address:
City, State and Zip
Phone Number:

Payment Method:

Check / Money Order: Complete and mail to the address above.

Credit Card (check one) (Visa) (MasterCard) (Discover) (American Express)

Card Number:

Expiration Date: 3 digit Vcode on back of card:

**Payment Method:**
Check / Money Order:	Complete and mail to the address above.
Credit Card (check one)	(Visa) (MasterCard) (Discover) (American Express)
	Card Number:
	Expiration Date: 3 digit Vcode on back of card:

Select Shipping Method:
Shipping methods are for shipping travel time only, orders are not shipped until the following day.

Check One: ( UPS Ground) ( UPS 3Day) ( UPS 2nd Day Air) ( UPS Next Day Air)

**Select Shipping Method:**
Shipping methods are for shipping travel time only, orders are not shipped until the following day.
Check One:	( UPS Ground) ( UPS 3Day) ( UPS 2nd Day Air) ( UPS Next Day Air)

The Item Code can be found on the webpage containing the item that you are wanting to order
right next to the "Add to Cart" button. Be sure to note any options / colors specific to your order
in the description. If you have any questions please call customer service at 1-800-804-9549.
Ordered Items:

Line # Item Code Quantity Description and Any Options Price Each

1


2

3

4

5

6

7

8

9

10

11

12

13

14

Sub Total:

Oklahoma Residents Only 7.5% Sales Tax:

Shipping Charges:

Total:

Line #	Item Code	Quantity	Description and Any Options	Price Each
1
2
3
4
5
6
7
8
9
10
11
12
13
14
			Sub Total:
			Oklahoma Residents Only 7.5% Sales Tax:
			Shipping Charges:
			Total: