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Fax or email your order and prescription directly to Advans CPAP. To FAX - print this form on your printer, neatly fill in the information, and send the completed form to (267) 295-8736. To EMAIL - copy and paste the form directly into a blank Microsoft Word document or similar program, fill in the information and attach to the email.
Email to: Billing@AdvansCPAP.com.
Your order will be confirmed and fulfilled upon receipt.
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To: Advans CPAP Order Fulfillment
Fax: (267) 295-8736
Email: Billing@AdvansCPAP.com
Today's Date ____________ |
Advans CPAP
12881 Knott St Suite 203
Garden Grove, CA 92841
Phone: 714 897-2727
Fax: 267 295-8736
Questions? Questions@AdvansCPAP.com |
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Shipping Information - please confirm via email
Name:______________________________
Email:______________________________
Company:___________________________
Address:____________________________
City:________________________________
State/ Province:______________________
Zip code:____________________________
Country:____________________________
Phone:______________________________
Fax:________________________________
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Billing Information - if different
Name:____________________________
Email:____________________________
Company:_________________________
Address:__________________________
City:______________________________
State/ Province:____________________
Zip code:__________________________
Country:___________________________
Phone:____________________________
Fax:______________________________
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Credit Card Information
Type: MasterCard, Visa, Discover or American Express (circle one)
Card Number:_________________________________________
Expiration Date:________________________________________
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Unit Price |
Total Price* |
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Circle your shipping method:
FedEx Ground - USA only
FedEx International- orders outside USA |
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Shipping costs will be tallied upon receipt of faxed order |
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Estimated total: |
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Note: Any additional item can be written on blank lines if needed.
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