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Dalton Medical Authorized Dealer Order Form Online Order
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4259 McEwen Road, Farmers Branch, Texas 75244
TEL: 469-329-5200 FAX: (972) 386-6615
Date (MM/DD/YY):        /        /               New Customer     OR
Order Person:                                 Existing Comp#:                                
Bill To:                                                                PO #:                          
City:                                   State:                     Zip:                    
Phone Number:                                   Fax Number:                                  
If different from above --
Ship To:                                                                                                         
Shipping Address:                                                                                                            
City:                                   State:                     Zip:                    
Contact:                                   Tel Number:                                  
Payment: VISA Master AME Card Holder            Exp. Date:      /     Card #         
Delivery: *Ship                         Will Call                         Others                        
QTY Item # Description Unit Price Extended Price
Special Instruction:
* It is the customer’s responsibility for any additional payment for Lift Gate or Inside Delivery services.