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RYDE HOSPITAL CONSIGNMENT STOCK PROGRAM - CUSTOMER ORDER FORM

*INVOICE WILL BE MAILED*


4 Stanton Rd **PLEASE FAX ORDER TO - 02 9624 4256 or (OFFICE USE ONLY )
Seven Hills NSW 2147 Date: ______________________
EMAIL: helen.knez@aidacare.com.au
Ph: 02 8706 2330
Fax: 02 9624 4256
FOR IMMEDIATE PROCESSING ** ORDER No: ________________
Email: helen.knez@aidacare.com.au **REFER TO PRICE LIST FOR CODES AND PRICES**
GP Entry by: ________________
DATE OF ISSUE:______/______/_______
PRESCRIBER DETAILS: PAYMENT OPTIONS: CLIENT / DELIVERY DETAILS:
CASH
NAME: _________________________________ CREDIT NAME: _________________________________ PHONE: ___________________
PHONE: ________________________________ CHEQUE ADDRESS: _________________________________________________________
EMAIL: _________________________________ (OFFICE USE ONLY) __________________________________________________________________
PAID YES NO
FORWARD INVOICE TO (Please Tick): DELIVERY INSTRUCTIONS (Please Tick):
 PRIVATELY FUNDED, invoice client direct
 OTHER FUNDING, please invoice Goods delivered & installed by OT from consignment stock.
NAME:__________________________ PHONE: _____________________ Goods not supplied. Not in stock on consignment. Please deliver and
ADDRESS: ____________________________________________________ supply direct to client.
_____________________________________________________________
List
QTY NEW ITEM CODE DESCRIPTION PRICE ($) Total ($)
(GST INC)

(PLEASE PRINT CLEARLY) I, ________________________________________, understand that the above equipment is to be provided to me by AIDACARE PTY LTD
at my own expense and that I will be responsible for the payment of any and all accounts relating to this order.
FULL NAME; _____________________________________SIGNATURE; ________________________________________DATE; _____/_____/_____