Advanced Rehab Therapy
Printable Order Form
Orders can be faxed, mailed, or phoned. All orders are shipped USPS. Overnight delivery is available on request. Please call for international shipping costs or email for further assistance.
  1. Fax the form to: (305) 378-4107
  2. Mail the form to: 7641 SW 126 Street, Miami, FL 33156
  3. Call: (800) 610-4278

First Name:______________   Last Name:_________________   Title:_______

Address:_________________________________________________________

City:_________________________   State:_______   Zip:________________

Phone (Daytime):____________________________

Facility Name:____________________________________________________


QTY. CAT. # TITLE PRICE AMOUNT
   $ $ 
   $ $ 
   $ $ 
   $ $ 
   $ $ 
Sub-Total   $ 
Florida Residents please add 7.0% sales tax   $ 
Shipping & Handling Charges (see below)   $ 
Total Amount (US dollars only)   $ 

Shipping & Handling - Orders shipped anywhere in the contiguous USA via USPS.
   US Mail ($6.25 first item, $1.50 each additional item)
Visa/MC No.:__________________________________   Exp Date:______________

Name on Card:________________________________   Amount (US):$__________


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