RxActuator Order Form

Order Form

Shipping Details

Ship To is required.
Street Address is required.
City is required.
State is required.
Zipcode is required.
Format: 123-456-7890
Valid Phone number is required. Please follow the format.
Valid Customer Email is required.

Bill To

Company Name is required.
Street Address is required.
City is required.
State is required.
Zipcode is required.
Format: 123-456-7890
Valid Phone number is required. Please follow the format.
Valid Email is required.
Description quantity Price each Total
Mini-Infuser SC-CRI pumps $75.00
Wearable Vest XXS $33.00
Wearable Vest XS $34.00
Wearable Vest M $36.00
Wearable Vest L $37.00
Wearable Vest XL $38.00
Shipping $25.00
Order Total

If you have any questions concerning this order
contact Doug Nutter 810-964-3248
dnutter@rxactuator.net

Make all checks payable to RxActuator, Inc.

Send payments to:

RxActuator, Inc
2100 N. Wilmot Rd. Suite 310
Tucson, AZ 85712

Terms: Net 30 days