Advanced Medical Support Services, Inc.

Chiropractor Order Form

This is the ordering form for chiropractors. If you have any problems, please call us toll-free at (800)448-2243!

* - Fields are Required

Ordered By:

Resale Permit/Business License Number

Address:

Zip:

City:

State:

Phone:

Fax:

E-mail (required for UPS ship notification)

URL:

Ship To: (if different) NO P.O. BOXES! Address:

Zip:

City:

State:

FREE SHIPPING ON ORDERS OF $75.00 OR MORE

Place Your Order

Description

Size

Quantity

Item Price

Total

Payment Information

We accept VISA, MASTERCARD, AMEX, Debit Cards (Shipping: call or e-mail for quote)

Credit Card Number: Name on Credit Card: Credit Card Expiration Date: Zip Code

Subtotal: Shipping Charge: Sales Tax (if applicable): Total:

Payable by check, M.O., Cert. or Cashiers check. Business checks cleared before processing order.

We stand behind our products 100%, YOUR total satisfaction is our goal! With products that touch the skin, we are unable to accept returns or re-stock if they have been used. If your order is defective in some way call us to resolve! If due to shipping, save all shipping materials and do not use product until the shipping issue is documented with the carrier. Contact us immediately! Thank you very much for your order!

Advanced Medical Support Services, Inc.

Comprehensive Solutions, Outstanding Service

Chiropractor Order Form

FREE SHIPPING ON ORDERS OF $75.00 OR MORE