visABILITIES PCI Compliant Secure Order Form
First Name: Last Name:
Facility: Department:
Address:    
City: State/Province:
Zip/Postal Code: Country:
Deliver To (if different from above)
First Name: Last Name:
Facility: Department:
Address:    
City: State/Province:
Zip/Postal Code: Country:
Contact Information
E-mail:
Fax:
Phone:    
Payment
PO Master Card Visa Amex
PO Number:    
Credit Card Number: Expires:
Name on Credit Card:    

Please enter the anti-fraud code:
For Master Card and Visa this is a three digit code on the back of your card as shown in the picture on the right.
*** For Amex it is a four digit code on the front of your card.

Shipping Method
UPS Ground to US or Canada (Actual Shipping Charges will be Charged/Invoiced)
Overnight (Actual Shipping Charges will be Charged/Invoiced)
2nd Day Air (Actual Shipping Charges will be Charged/Invoiced)
Outside Continental U.S. and Canada (Actual Shipping Charges will be Charged/Invoiced)
Order Totals
Qty Description Each Amount
Brain Injury Visual Assessment Battery for Adults $595.00 $
Sub-Total: $

Sales Tax:
We are located in Kansas and do not have tax exempt status

$
Total U.S. plus Actual Shipping Charges : $

Please submit your order only once! There will be a momentary delay for secure processing.

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