Ordering Your Injury Prevention Products By Fax Order Form

MAIL - FAX ORDER FORM

Clinical Technology
2B Atarangi Rd, Greenlane
Auckland, New Zealand.
PO Box 17 077, Greenlane,
Auckland, New Zealand.
Fax:- +64 9 529 1199
GST No:- 720-64771

For your convenience you can enter all details on screen prior to printing
this form, all entries will be included on the printed page.

From : Date :

Description		Quantity	PRICE ($NZ)	APPROX ($US)	Total ($NZ)
	Percutane™ (45g container)		12.95	6.50
	Percutane™ (100g container)		19.95	10.00
	THERMASTRAP Adjust-a-Cup (Ankle & Foot)		34.95	17.50
	THERMASTRAP Arm & Elbow		26.95	13.50
	THERMASTRAP Back		64.95	32.50
	THERMASTRAP Calf & Shin		38.95	19.50
	THERMASTRAP Knee		44.95	22.50
	THERMASTRAP Multi-purpose strap		29.95	15.00
	THERMASTRAP Neck		26.95	13.50
	THERMASTRAP Thigh & Hamstring		49.95	25.00
	THERMASTRAP Wrist & Hand		25.95	13.00
SubTotal	(1. click in box for sub-total)
Shipping	(2. click in appropriate box)
TOTAL	(3. click in box for grand total)

Credit Card Details
Credit Card Type:	American Express VISA Mastercard
Card Number:	- - -
Expiry Date:	Month: Year:

Signature:	_______________________________________________

Personal Details
Title:	Mr Mrs Ms Miss Dr
First Name:
Last Name:	*
E-mail:	*
Phone:	*
Fax:
Street Address:	*

City:	*
Zip/Post Code:	*
State/Province:	*
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* - Required fields.

All prices are in New Zealand dollars and are inclusive of GST (NZ residents only).
All credit cards will be deducted in New Zealand dollars.
All other prices are indicative only, final purchase price is subject to currency fluctuations and will be based on the rate used by Visa, Mastercard or American Express.
Our Guarantee:- If for some reason your are not completely satisfied with any of our products, simply return it to us within 30 days of purchase and we will gladly refund your money in full.
Please note that shipping and handling costs are not refundable.