Five Dock Purchase Order Form

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ALFRED IMAGING GROUP

FIVE DOCK MEDICAL IMAGING - PURCHASE ORDER FORM

Delivery Address:

Five Dock Medical Imaging

144 Great North Road

Five Dock - 2046

Large X-ray Envelope 10,000 20,000 others

If others, Please Specify

Medium X-ray Envelope 10,000 20,000 Others

If others, Please Specify

A4 Letterhead 30,000 50,000 Others

If others, Please Specify

A4 Referral Sheets (100 in a pack) 300 Pads 600 Pads Others

If others, Please Specify

A5 Referral General Pad (50 in a pad) 300 Pads 600 Pads 1000 Pads Others

If others, Please Specify

A5 Referral Dr's Personalised Pad (50 in a pad) 2 Pads 4 pads 6 pads Others

If others, Please Specify

Referring Doctor

Please enter the referring Doctor's information below.

Doctor's Name

Address

Phone

Fax

Provider No

Patient Labels 10,000 15,000 Others

If others, Please Specify

Appointment Cards 5,000 10,000 Others

If others, Please Specify

DL Envelopes 5,000 10,000 Others

If others, Please Specify

DL with Window Envelopes 5,000 10,000

If others, Please Specify

Delivery Date

Notes

Ordered By

Approved By

Attachment