SPECIFY PRODUCT & QUANTITY TO BE QUOTED:

 DynEx1 , $799.99 Catalog List Price

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 DynEx2 , $999.99 Catalog List Price

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 Other, describe request below

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SPECIFY SHIPPING PREFERENCE:

 Most Economical shipping
                       48 cont. states: single unit $12.00 
         
 Second-Day shipping:
                       48 cont. states, single unit $25.00, Alaska $40, Hawaii $50
         
 Outside the USA: ranges from $70.00 to $100.00 except Canada
   Canadian costs range from $25 to $50 excluding import taxes and fees.         

CUSTOMER TYPE & INFORMATION:

Name (required) 



 Medical professional: Specify Type (required) 



 Reseller: Specify Type (required) 



 Other: Specify Type (required) 



Mailing or Street address 



Suite/Mail stop 



City, State, Zip 







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eMail (required) 



Payment Method to be used.

 Credit Card 

Type 
[Choose one]
Visa
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American Express
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 Check (check must clear before shipment)

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Where did you learn about the DynEx product ?
(please be as specific as possible)