NIH Stroke Scale Exam Order Form21
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NIH STROKE SCALE EXAM ORDER FORM Date: Site Name: Person Placing Order: Phone Number: Fax Number: Mailing Address*: City, State Zip: *Please note orders cannot be sent to P.O. Boxes. Item Code Product Name Quantity Price Per Unit Order Amount NC1A NIH Stroke Scale Exams $25.00* Add postage and handling for materials (see chart below) + INVOICE TOTAL $ PAYMENT INFORMATION (please check one): Check enclosed (payable to National Stroke Association – NIHSS) Purchase order # Credit card: Visa MasterCard AMEX Card number: Exp. Date: PRINT cardholder name: NATIONAL STROKE ASSOCIATION MATERIALS SHIPPING & HANDLING Order Amount Within U.S. Outside U.S. $0 - $35 add $8 Call customer service $35.01 - $50 add $9 Call customer service $50.01 - $75 add $10 Call customer service $75.01 - $100 add $12 Call customer service $100.01 - $125 add $14 Call customer service $125.01 - $150 add $16 Call customer PLEASE RETURN THIS FORM TO: National Stroke Association Customer Service 9707 E. Easter Lane, Bldg. B Centennial, CO 80112 Phone:(303) 649-9299 1-800-STROKES Fax: (303) 649-1328 Web: www.stroke.org
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nih stroke scale exam
Transcript of NIH Stroke Scale Exam Order Form21
NIH STROKE SCALE EXAM ORDER FORM
Date:
Site Name:
Person Placing Order:
Phone Number:
Fax Number:
Mailing Address*:
City, State Zip: *Please note orders cannot be sent to P.O. Boxes.
Item Code Product Name QuantityPrice Per
UnitOrder
Amount
NC1A NIH Stroke Scale Exams $25.00* Add postage and handling for materials (see chart below) +
INVOICE TOTAL $
PAYMENT INFORMATION (please check one):
Check enclosed (payable to National Stroke Association – NIHSS) Purchase order # Credit card: Visa MasterCard AMEX
Card number: Exp. Date:
PRINT cardholder name:
NATIONAL STROKE ASSOCIATION MATERIALS
SHIPPING & HANDLINGOrder Amount Within U.S. Outside U.S.$0 - $35 add $8 Call customer service
$35.01 - $50 add $9 Call customer service
$50.01 - $75 add $10 Call customer service
$75.01 - $100 add $12 Call customer service
$100.01 - $125 add $14 Call customer service
$125.01 - $150 add $16 Call customer service
$150.01 - $175 add $19 Call customer service
$175.01 - $200 add $22 Call customer service
> $200 Call customer service Call customer service
All materials are shipped UPS Ground. Shipping charges for orders over 30 lbs. will be individually assessed. Please allow 2 to 4 weeks for delivery. Special handling such as: orders over $200, 2-day, overnight and international shipping costs are determined on a case-by-case basis – call Customer Service for details (1-800-STROKES).
PLEASE RETURN THIS FORM TO:
National Stroke AssociationCustomer Service
9707 E. Easter Lane, Bldg. BCentennial, CO 80112
Phone: (303) 649-92991-800-STROKES
Fax: (303) 649-1328Web: www.stroke.org
*National Stroke Association Stroke Center Network (SCN) members may order copies of the exam at no charge, which includes scoring and certificates of completion.
Nonmembers pay $25 per exam. For more information on how to become an SCN member, contact [email protected] or 303-754-0935.
