Quality Medical Inc.
Your Medical Supply Solution!

Toll Free: 1-877-878-9882
Quality Medical Inc.

Type in your Information, Then PRINT this Order Form on Your Printer
Quality Medical Inc. 4829 S. Kirk Way., Aurora Colorado 80015 - Fax: 1-800-846-7609 (See Instructions)
Ship to (name):
Street Address:
City, State & Zip:
Phone Number: E-mail:

Credit Card :  Master Card: Visa: Discover: American Express:

Card No.: - - -   Expiration Date ( 00/00 ): /
Authorization No. on Back of Card (See Instructions) :

Name As It Appears On Card:
Billing Street Address:
Billing City, State & Zip:
Billing Phone Number:
Qty Product Description - SKU Number Price Each Total
*Colorado residents, ADD 3.95 % Sales Tax
( If unknown we will add it for you, See Instructions ) SHIPPING

Signature _____________________________________ Date ______________


INSTRUCTIONS: Copy down the information on the products you wish to purchase, including the SKU number. If you do not know the shipping cost, we can add it for you or call 1-877-878-9882.
Type in the information above and Print this form to your printer using the print button.
Fill out the form COMPLETELY.
Fax or Mail ( ONLY ) to us with a copy of your prescription if required.
Upon receipt, we will E-mail you a confirmation of your order and any shipping charges that may apply.
Please provide your E-mail address.

We accept: Master Card, Visa, Discover, American Express, Checks*, Money Orders, and Wire Transfer's. Sorry No Cash Payments Accepted, and No COD's.
*Checks require a 3-5 day clearing period from the time we receive it, before your item will ship.
For Credit Card transactions, we ask that you give us your 3 digit Authorization Number, located on the back of your card for Master Card, Visa, Discover. The AMEX Card number is on the front of the card located top right ( 4 digits ).  These authorization numbers verify that the credit card used for this transaction is in hand and limits fraudulent transactions.