Labels:text | screenshot | diagram OCR: 00> <>> INVOICE INVOICE NUMBER (DELIVERY / PICKUP RECEIPT) ADDRESS F CITY STATE ZIP JCAHO Accredited PLEASE REMIT TO: P.O. BOX 860 LONG BEACH, CA 90801 H T ADDRESS P TELEPHONE CITY STATE ZIP NUMBER INVOICE DATE ACCOUNT NUMBER CUSTOMER P.O. NUMBER SHIP VIA PAYMENT TERMS PAYMENT RECEIVED ON THIS INVOICE ON ACCOUNT CHECK NUMBER CASH CASH RECEIVED BY QTY. ORD. SHIPPED BACK ORD MFG. NO. ITEM DESCRIPTION EQUIPMENT SHIPPED NET SALE TAX CARTAGE EQUIPMENT RETURNED TOTAL CUSTOMER PAYS THIS AMOUNT MPORTANT NOTICE TO CUSTOMERS: Donot sign this agreement beforeyou read it or if it contains blank spaces that should be filled in. Your signature indicates that you have read, understand and agree tothe entire agreement, induding the terms and conditions printed on the reverse side. Rental equipment will not be picked up until the Company is notified. Returned merchandise is subject to arestocking charge. Your signature acknowledges receipt of the informational items checked below and the delivery / pickup of the products / services which were delivered in clean and good working condition. A Company representative has madethe necessary adjustments, if needed, and completely demonstrated the proper care and useto your satisfaction. New Patient Information Packet. [ Product Safety and Cleaning Instructions. [ Patient Rights and Responsibilities. [ Product Operating and Maintenance Instructions PATIENT/CUSTOMER SIGNATURE RELATIONSHIP COMPANY REPRESENTATIVE @ BOWERS COMPANIES 11/94
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