SALES ORDER FORM for BOOKING

Complete Name of the Hospital / Drugstore / MD:

Complete Address :
Customer Code / Number : Customer Tel. No. :
Purchase Order ( P. O. ) Number : Date of Sales Order :
Medical Representative Full Name : Territory Code :

QUANTITY PRICE AMOUNT

ITEM ITEM DESPCRIPTION PACKAGING List Price per Piece per piece per box per piece per box per piece per box
CODE PROPOFOL ANAESTHESIA
60F62 Propofol - Lipuro Glass Bottle 1% 10mg 50ml 50 ml Bottle 1,080.00 0 0
60F63 Propofol - Lipuro Glass Ampoule 1% 10mg 20ml 20 ml Amp / bx of 5's 480.00 0 0
PLASMA VOLUME REPLACEMENT SOLUTION 0 0
60B80 GELOFUSINE EP 500ML PH Box of 25's 623.75 0 0
ANTI INFECTIVE 0 0
60537 METRONIDAZOLE IV INF 500MG EP 100ML PH Box of 48's 55.13 0 0
CELSITE ACCESS PORTS 0 0
60032 CELSITE HIGH FLOW CAT Per piece 23,400.00 0 0
60518 CELSITE ADULT PERITONEAL PORT Per piece 27,300.00 0 0
60864 CELSITE BRACHIAL TIT/EPOXY Per piece 30,545.45 0 0
60865 CELSITE BABY PORT Per piece 27,950.00 0 0
- CELSITE WITHOUT ACCESSORIES Per piece 18,200.00 0 0
CYTOCAN NON-CORING HUBER NEEDLES 0 0
60115 CYTOCAN 20G X 15MM STERILE Box of 25's 715.00 0 0
60116 CYTOCAN 22G X 15MM STERILE Box of 25's 715.00 0 0
60118 CYTOCAN 22G X 25MM STERILE Box of 25's 715.00 0 0
TOTAL 0 0
 SALES ORDER FORM for BOOKING
Complete Name of the Hospital / Drugstore / MD: San Pablo Medical Centeer
Complete Address : Brgy. San Rafael, Maharlika Highway, San Pablo, Laguna
Customer Code / Number : Customer Tel. No. :
Purchase Order ( P. O. ) Number : 5292 Date of Sales Order : 26-Jan
Medical Representative Full Name : Jonalyn S. de leon Territory Code : SMSL6

QUANTITY PRICE AMOUNT

ITEM ITEM DESPCRIPTION PACKAGING per piece per box per piece per box per piece per box
CODE PROPOFOL ANAESTHESIA
60F62 Propofol - Lipuro Glass Bottle 1% 10mg 50ml 50 ml Bottle 0.00 0.00
60F63 Propofol - Lipuro Glass Ampoule 1% 10mg 20ml 20 ml Amp / bx of 5's 6 2,400 0.00 14,400.00
PLASMA VOLUME REPLACEMENT SOLUTION
60B80 GELOFUSINE EP 500ML PH Box of 25's 0.00
ANTI INFECTIVE
60537 METRONIDAZOLE IV INF 500MG EP 100ML PH Box of 48's 0.00 0.00
CELSITE ACCESS PORTS
60032 CELSITE HIGH FLOW CAT Per piece 0.00 0.00
60518 CELSITE ADULT PERITONEAL PORT Per piece 0.00 0.00
60864 CELSITE BRACHIAL TIT/EPOXY Per piece 0.00 0.00
60865 CELSITE BABY PORT Per piece 0.00 0.00
- CELSITE WITHOUT ACCESSORIES Per piece 0.00 0.00
CYTOCAN NON-CORING HUBER NEEDLES
60115 CYTOCAN 20G X 15MM STERILE Box of 25's 0.00 0.00
60116 CYTOCAN 22G X 15MM STERILE Box of 25's 0.00 0.00
60118 CYTOCAN 22G X 25MM STERILE Box of 25's 0.00 0.00
TOTAL 0.00 14,400.00
14,400.00
Customer Full Name Customer Signature