MIC Oxygen Unit Refill Request

Company Name:   
Shipping Address:
City: State:   Zip:
Your Name: Phone:
E-Mail Address:

What size Oxygen tank do you have? "D" or "E" Select Oxygen Cylinder Needed "D" Tank (In a soft leather or cloth bag) "E" Tank (Larger tank kept on a stand)

So that we can update our records, be sure to give the location and department where the unit is kept.

MIC First Responder Kit - Reorder Form

Company Name:   
Shipping Address: 
City: State: Zip:
Your Name: Phone:
E-Mail Address:

LIST OF RESPONDER KIT CONTENTS
* Check the box for needed components. If you need additional quantity of a certain item enter the quantity and PART# in the Additional Data box at the end of this form.
* The prices below DO NOT include shipping & handling or any applicable sales taxes.

                           PART #        QUANTITY                  COMPONENT                       PRICE
                     12-10-54                 1                      Rescue Breather Pak                  $16.95
                     02-16-25                 1                    Face Mask w/ Eye Shield              $4.50
                     02-09-56                 2                         Eye Dressing Pak                     $4.25
                     02-12-01                 1                         PVP Iodine Wipes                     $1.60
                     02-05-10                 1                1728 sq in. Gauze Compress           $2.95
                     02-07-95                 1                     Adhesive Bandage Pak                $1.10
                     02-07-66                 1                2" Offset Bandage Compress           $4.80
                     02-07-68                 2                4" Offset Bandage Compress           $2.95
                     02-03-05                 1                  4"x 6 yard Gauze Bandage              $2.95
                     02-03-70                 2                       Triangular Bandage                     $2.95
                     02-06-67                 2                                 Cold Pak                             $1.60
                     02-11-55                 1                         Burn Ointment Pak                     $2.50
                     02-10-30                 1                2" x 2" Water Gel Sterile Burn           $7.95
                     02-10-31                 1                4" x 4" Water Gel Sterile Burn           $11.00
                     02-99-99                 1                      Latex Medical Gloves                   $2.45

                                                                                         Special Items
                     12-70-10                 1                 Bloodborne Pathogens Refill           $29.95
                     01-06-67                 1                         Empty Plastic Case                  $29.95

                                                   Enter any additional info in the box below:
       

                                To process your order, hit the button below: