Order Form

ORDER FORM
Please complete this form and click 'SUBMIT'.

Practice Name:
BHF Practice Number:
Physical Address (use comma's):
Postal Address (use comma's):
Tel no:
Fax No:
Cell Number:
Email Address:
Person Submitting the Request
Quote No:
Order Details:
Item 1:	Qty: Comments:
Item 2:	Qty: Comments:
Item 3:	Qty: Comments:
Item 4:	Qty: Comments:
Item 5:	Qty: Comments:
Other Items (Please give full details):
Total Value: R
Method of Payment:
General Comments:
Optimax Account details:	Standard Bank Fourways Branch Code 009953 Account number: 402 092 589 PLEASE FAX THE DEPOSIT / PAYMENT SLIP TO US ON (011) 706-0959. Thank you