Carolina Medical Products Company Post Office Box 147 □ Farmville, North Carolina 27828 (252) 753-7111 1-800-227-6637

ABSORBASE^® ORDER FORM

(Effective February 25, 2003)

ABSORBASE^®

NDC 46287-507-16

PRICE PER POUND (454 GRAMS)		$8.50
QUANTITY ORDERED	X
SUBTOTAL	=
SHIPPING & HANDLING ($5.00 for 1 – 5 pounds; $10.00 for 6 or more)	+
TOTAL	=

Please provide your address below and enclose a personal check or money order made payable to Carolina Medical Products Co. We will send the product as soon as we receive your check or money order. Please note: We can only send 1 pound to a P.O. Box; 2 or more pounds require a street address.

Name

P.O. Box (see above)

Or

Street Address

City

State

ZIP Code