Pharmacy Products Order Form Facility/ Company Name(Required) Hospital DEA Number Approximate Bed Size Purchase Order #(Required) Contact PersonName(Required) First Last Phone(Required)Email(Required) Wholesaler Shipping AddressAttention To(Required) Address Street Address Address Line 2 City State Zip Code Click here to use Shipping Info as Billing Info: Billing AddressCompany Name: Address Street Address Address Line 2 City State Zip Code Select Products:SecurSeal® Series 10 Baxter's Viaflex® Bags and Mini Bags™ Containers, B. Braun's PAB® Containers & other containers with similar sized ports. 1,000 units per box 10 - 100 Silver 10 - 200 Blue 10 - 300 Red 10 - 400 Green 10 - 500 Yellow 10 - 600 Orange 10 - 700 Tan SecurSeal® Series 13 13mm Vial Tops 1,100 units per box 13 - 100 Silver 13 - 200 Blue 13 - 300 Red 13 - 400 Green 13-500 Yellow 13 - 600 Orange SecurSeal® Series 20 20mm Top Vials 1,000 units per box Also fits other large port bags 20 - 100 Silver 20 - 200 Blue 20 - 300 Red 20 - 400 Green 20 - 500 Yellow 20 - 600 Orange 20 - 700 Tan SecurSeal® Series 28 28mm Bottles & Piggyback Containers 1,000 units per box Also fits other large port bags 28 - 100 Silver 28 - 200 Blue 28 - 300 Red 28 - 400 Green 28 - 500 Yellow 28 - 600 Orange SecurSeal® Series 30 Large Bag Seal 1,000 units per box Also fits Hospira VisIV® Containers and other large port bags 30 - 100 Silver30 - 200 Blue30 - 300 Red30 - 400 Green30 - 500 Yellow30 - 600 Orange SecurSeal® Series 55 Hospira Bag Side Injection Port Bag 1,000 units per box 55 - 100 Silver 55 -200 Blue 55 - 300 Red 55 - 400 Green 55 - 500 Yellow 55 - 600 Orange SecurSeal® Syringe Seal 1,100 seals per roll 80 -800 ChemoSeal® Series 301,000 units per box Series 30 Quantity YellowChemoSeal® Series 101,000 units per box Series 10 Quantity YellowComplimentary Chrome Hanging Dispenser Rack Hanging Dispenser Rack Quantity Ordering InformationFree Shipping – No Minimum Purchase Orders and Major Credit Cards accepted Wholesaler Drop Shipments Available- No Extra Charge All products carry our customer satisfaction guarantee. If for any reason you are not satisfied with our product or service, we will make it right.Notes
