Order form - Performance Attainment Associates - Spinal Assessment Instruments - CHROM, BROM, PALM, UIOI, Range of Motion Intrument, Inclinometer

Ordering information

To place an order please fill out the form below. Once completed, submit the order by printing and faxing, Mailing, or calling it in:

Phone - (800) 835-2766 or (651) 257-3040

Fax - (651) 257-7210

PO Box 528
Lindstrom, MN 55045
(800) 835-2766
(651) 257-3040
(651) 257-7210 - Fax

info@spineproducts.com

International Customers

Bank Wire Transfer

USBANK, 120 South 6th Street, Minneapolis
Routing Number 091000022
Performance Attainment Associates
Account Number Available Upon Request

Customer Information

Facility Name

Your Name

Street Address

Address 2 (Suite # , No PO boxes please)

City

State Zip Code

Country

Phone 1

Fax

E-Mail Address

Order Information

Product(s):		BROM Basic $ 395.00
		BROM II $ 495.00
		BROM II Video $ 20.00
		CROM Basic $ 395.00
		CROM Deluxe $ 495.00
		CROM Video $ 20.00
		PALM $ 225.00
		Universal Inclinometer - UI01 $ 69.50
		Universal Inclinometer - UI01 2 for $125.00

Extra Parts:		CROM Rotation Arm $ 100.00
		CROM Mainframe $ 200.00
		CROM Nose Piece Set of 2 $ 20.00
		CROM Straps One set $ 20.00
		CROM Magnetic Reference $ 125.00
		CROM Upgrade Forward head unit, deluxe case and foam, nose piece, tape measure $ 125.00
		PALM Tips All three sets $ 25.00


Other: (List other products)

Shipping & Handling (See Chart)		Shipping and Handling Rates UPS ground - Shipping = $10.00 each UPS next day - Shipping = $30.00 each *International orders $75.00 per instrument No shipping charge when order is prepaid by check
Order Total:


* Please call us for payment information (800) 835-2766 or (651) 257-3040

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Please Fax, Mail or call in the order form