Westhill Home Medical Order Form - Call: 1-800-924-8313

Not sure what to order?
For more information,
click on pictures.

Call 1-800-924-8313
We want to make sure you receive
the products you need.

Please print this page, complete printed form and mail to:
Westhill Home Medical, 920 N Westhill Blvd, Appleton, WI 54914
Questions? Call: 800-924-8313 or 920-749-3777 Fax: 920-749-3763
E-mail Questions to: order-questions@westhillhm.com

Name
Billing Address
City/State/Zip
Day Phone #
e-mail Address
Shipping Address Same As Billing. If not, please complete address section below.
Name
Shipping Address
City/State/Zip

Qty.	Stock #	Description	Size	Price

* Free shipping to	Sub Total:	_______.____
48 Continental	Wisconsin Residents Add 5% Sales Tax:	_______.____
United States ONLY.	Shipping/Handling (* Included in Price):	_______.____
Payment Method:	Total Enclosed:	_______.____

Check or Money Order Payable to: Westhill Home Medical
American Express Discover MasterCard VISA
Credit Card Number
Expiration Date
Name on Card
Signature of Card Holder