Pharmacy Products Order Form Facility/ Company Name(Required)Hospital DEA NumberApproximate Bed SizePurchase Order #(Required)Contact PersonName(Required) First Last Phone(Required)Email(Required) WholesalerShipping AddressAttention To(Required)Address Street Address Address Line 2 City State Zip Code Click here to use Shipping Info as Billing Info: Billing AddressCompany Name:Address Street Address Address Line 2 City State Zip Code Select Products:SecurSeal® Series 10 Baxter's Viaflex® Bags and Mini Bags™ Containers, B. Braun's PAB® Containers & other containers with similar sized ports. 1,000 units per box 10 - 100Silver 10 - 200 Blue 10 - 300 Red 10 - 400 Green 10 - 500 Yellow 10 - 600 Orange 10 - 700 Tan SecurSeal® Series 9 9mm Vial Tops 1,100/Roll 9 - 100 Silver 9 - 300 Red SecurSeal® Series 13 13mm Vial Tops 1,100/Roll 13 - 100 Silver 13 - 200 Blue 13 - 300 Red 13 - 400 Green 13-500 Yellow 13 - 600 Orange SecurSeal® Series 20 20mm Top Vials 1,000 units per box Also fits other large port bags 20 - 100 Silver 20 - 200 Blue 20 - 300 Red 20 - 400 Green 20 - 500 Yellow 20 - 600 Orange 20 - 700 Tan SecurSeal® Series 28 28mm Bottles & Piggyback Containers 1,000 units per box Also fits other large port bags 28 - 100 Silver 28 - 200 Blue 28 - 300 Red 28 - 400 Green 28 - 500 Yellow 28 - 600 Orange SecurSeal® Series 30 Large Bag Seal 1,000 units per box Also fits Hospira VisIV® Containers and other large port bags 30 - 100 Silver30 - 200 Blue30 - 300 Red30 - 400 Green30 - 500 Yellow30 - 600 Orange SecurSeal® Series 55 Hospira Bag Side Injection Port Bag 1,000 units per box 55 - 100 Silver 55 -200 Blue 55 - 300 Red 55 - 400 Green 55 - 500 Yellow 55 - 600 Orange SecurSeal® Syringe Seal 1,100 seals per roll 80 -800 ChemoSeal Series 101,000 units per box Series 10-CHEMO QuantityYellowChemoSeal Series 301,000 units per box Series 30-CHEMO QuantityYellowHazardous Seal Series 101,000 units per box Hazardous Seal Series 10 QuantityYellowHazardous Seal Series 301,000 units per box Hazardous Seal Series 30 QuantityYellow Complimentary Chrome Hanging Dispenser Rack Hanging Dispenser Rack Quantity Ordering InformationFree Shipping – No Minimum Purchase Orders and Major Credit Cards accepted Wholesaler Drop Shipments Available- No Extra Charge All products carry our customer satisfaction guarantee. If for any reason you are not satisfied with our product or service, we will make it right.Notes
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