The Phipps & Bird Portable Dialysate Warmer TM

 for Continuous Ambulatory Peritoneal Dialysis Patients


This is NOT an electronic form. Because of credit card security we have created a printable form only. Please print out the form below, fill in the following fields, and either fax or mail it to Phipps & Bird. Thank you.


1519 Summit Avenue,
Richmond, Virginia 23230
Phone: 804-254-2737
or toll free: 800-955-7621 (USA)
Fax: 804-254-2955

( * ) Please fill in all required fields.

* Name:     ______________________________________________________
* Company:     ______________________________________________________
* Address:     ______________________________________________________
* City:     ______________________________________________________
* State:     ______________________________________________________
* Zip Code:     ______________________________________________________
* Country:     ______________________________________________________
* Phone:     ______________________________________________________

Price: $289 + ____________ (Virginia Sales Tax) = ____________ (Total)

Color Choice: Navy, Forest Green, Black


Payment Method (check one):

Check or Money Order. Enclose check or money order, made payable to Phipps & Bird, for $289 (Virginia residents add 4.5% state sales tax). Shipping charges are included (Continental U.S.A. only).

Credit Card. (check one): VISA MasterCard American Express

* Card Holder's Name (please print):     __________________________________
* Card Holder's Signature:     __________________________________
* Credit Card Number:     __________________________________
* Expiration Date:     __________________________________


If you know someone who would like to order the P&B Portable Dialysate Warmer, please feel free to print off and give them a copy of this order form, or call us at 1-800-955-7621 for additional brochures and forms.

All orders delivered in 2 to 3 weeks.

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