Zyno Medical LLC
Zyno Medical Follow-up IV Set Sales Order Form 

1: Order Information
Order Date:
Bill to Name:
Bill to Address:
City, ST Zip Code:
Phone:
Fax:
E-mail Address:

2: Shipping Information If SHIP TO is same as BILL TO, Check Here:
Ship to Name:
Ship to Address:
City, ST Zip Code:
Phone:
Fax:
E-mail Address:

3:Specific Order Request
Contact Person:
P.O. Number:
Shipping Method:
Sales Order #:
Payment Terms: (Net 30 Days)

Note: Shipments will be UPS Ground unless otherwise directed. Customer responsible for shipping costs

4: IV Sets
ITEM DESCRIPTION CASES ORDERED
80070 Primary Straight 50/ca
80071-D 1 Y below pump 50/ca
80071-DF 1 Y below pump with 0.22 filter 50/ca
80071-P 1 Y above pump 50/ca
80071-PF 1 Y above pump with 0.22 filter 50/ca
80072 2 Y site one above one below the pump 50/ca
80072-F 2 Y site with 0.22 filter 50/ca
80075 Secondary Straight 50/ca
70070-N056 Primary Straight with anti-freeflow clamp for Z-800F pump 50/ca
70071-P056 1 Y above pump with anti-freeflow clamp for Z-800F pump 50/ca
70071-D058 1 Y below pump with anti-freeflow clamp for Z-800F pump 50/ca
70072-N058 2 Y site with anti-freeflow clamp for Z-800F pump 50/ca