Calgonate®

Order Form

PO# (optional):

Company name:

Telephone #:

ext.

First name:

Last name:

E-mail Address:

Shipping Address

Address:

Suite:

City:

Zip code:

State:

Country:

Billing address

Same as shipping address

Address:

Suite:

City:

Zip code:

State:

Country:

Accounts Payable#
(If different from main number):

ext.

Please send pair(s) of neoprene gloves
(no minimum order)

Please send tubes of Calgonate
(3 tube minimum)

Please choose one:

	Send invoice by mail
	Fax invoice to:
	Send invoice by email
	Please call for credit card information.

For pricing and purchasing information please call:
1-866-570-4170
Or upon receiving your order, you will be contacted for pricing confirmation.

Hydrofluoric Acid Burns
Emergency medical treatment for HF burns

All orders will be shipped within 1 business day.
. . . . . . . . . . . . . . . . .
Calgonate is manufactured in a FDA-GMP approved facility.

QUESTIONS? 1-866-570-4170