s40 45 65 72 ti reorder form (062513)

Bill to: Ship to:  

DOS:

Set Type:

DrillsQty Product No. Price (ea) Qty. Product No. Price (ea) Qty. Product No. Qty Product No. Price (ea)

S40‐20T‐11 S65‐30T‐20 K100‐11S Z402‐100‐27

S40‐22T‐11 S65‐35T‐20 K150‐11S Z402‐150‐45

S40‐24T‐11 S65‐40T‐20 K100‐14S Z400‐230‐55

S40‐26T‐11 S65‐45T‐20 K100‐16S Z401‐150‐50

S40‐28T‐11 S65‐50T‐20 K150‐16S

S40‐30T‐11 S65‐55T‐20 K150‐20S

S40‐32T‐11 S65‐60T‐20 K230‐20S

S40‐34T‐11 S65‐65T‐20 K250‐20S

S40‐36T‐11 S65‐70T‐20 K300‐20S

S40‐38T‐11 S65‐75T‐20 K230‐25S

S40‐40T‐11 S65‐80T‐20 K300‐25S

S40‐45T‐11 S65‐85T‐20 K230‐20D

S40‐50T‐11 S65‐90T‐20 K250‐20D

S40‐55T‐11 S65‐95T‐20 K300‐20D

S40‐60T‐11 S65‐100T‐20

S65‐105T‐20

S45‐20T‐16 S65‐110T‐20

S45‐22T‐16 S65‐115T‐20

S45‐24T‐16 S65‐120T‐20

S45‐26T‐16

S45‐28T‐16 S72‐50T‐25

S45‐30T‐16 S72‐55T‐25

S45‐32T‐16 S72‐60T‐25

S45‐34T‐16 S72‐65T‐25

S45‐36T‐16 S72‐70T‐25

S45‐38T‐16 S72‐75T‐25

S45‐40T‐16 S72‐80T‐25

S45‐45T‐16 S72‐85T‐25

S45‐50T‐16 S72‐90T‐25 Prices for </=4lbs Price

S45‐55T‐16 S72‐95T‐25 First a.m. (location dependent) 100.00

S45‐60T‐16 S72‐100T‐25 Priority overnight, 10:30 am 65.00

2nd Day 30.00

Note:  All orders received by 3:30 pm CST will be shipped   3rd Day 22.50

the same day.  Ground 13.50

If SHIPPING PREFERENCE is not checked, order will 

ship via Ground service.

PURCHASE ORDER TOTAL       $ ______________

Shipping & Handling Charges

Special Instructions/patient sticker:

   Re‐order / Circulation FormPhone:  800‐521‐5002     |    Fax: 866‐606‐4911    |    Email: Customerservice@vilex.com     |     www.vilex.com

4.0 Lag Screw

4.5 Lag Screw

PO#Physician:                                                

Patient Identifer:

7.2 Lag Screw 

(Facility or                

Sales Rep Address)

Facility Contact:     

Price (ea)

Guide Wires (Kwires)6.5 Lag Screw

Sales Rep:Lag Screw Titanium (BLUE) ‐‐‐ 4.0, 4.5, 6.5, 7.2

Product Reference: All sizes shown in mmS‐xx‐yyT‐zz (S=lag screw, xx=screw diameter, yy=screw length, T= titanium, zz=cannulation,                

Kxxx‐yyS (K=Kwire, xxx=length, yy=diameter, S=single trocar, D=Drill Tip)

Vilex Reorder Form 08/05/11