Medical Oxygen Regulator â Order Form - Air Liquide Healthcare ...
Medical Oxygen Regulator â Order Form - Air Liquide Healthcare ...
Medical Oxygen Regulator â Order Form - Air Liquide Healthcare ...
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<strong>Medical</strong> <strong>Oxygen</strong> <strong>Regulator</strong> – <strong>Order</strong> <strong>Form</strong>Attention : AIR LIQUIDE <strong>Healthcare</strong>Fax number : NSW/ACT: (02) 8338 9797VIC/TAS: (02)9364 7482For ALH Office Use OnlyConfirmed by: Service Call No: Date:Customer Number:CUSTOMER INFORMATION<strong>Order</strong> Reference:Business Name:Contact Person:Delivery Address:Phone Number:Comments:Fax Number:Item Number Product Description Price (Ex. GST) Quantity Total Price (Ex.GST)4542S<strong>Medical</strong> <strong>Oxygen</strong> Pin Index$399<strong>Regulator</strong> – NOVA 40GST:Grand Total:Doctor’s Name:<strong>Order</strong>ed by:(PleasePrint Name) Signature: DateAIRLIQUIDE <strong>Healthcare</strong> Pty. LtdUnit 5/476 Gardeners Road,Alexandria NSW 2015Toll free 1300 36 02 02www.airliquidehealthcare.com.auAIR LIQUIDE <strong>Healthcare</strong> Pty. Ltd40 Bunnett Street,North Sunshine VIC 3020Toll free 1300 36 02 02www.airliquidehealthcare.com.au
<strong>Regulator</strong>y Requirement - “<strong>Medical</strong> <strong>Oxygen</strong> Valve Changeover” –Equipment SurveyDear Customer,Please be advised that due to Australian Government regulatory requirements (Standard AS2473) there will bea mandatory change of all Type 10 oxygen valves (D, E and G size cylinders) to the current Pin Indexedsystem : this means that you will have to upgrade your <strong>Medical</strong> <strong>Oxygen</strong> <strong>Regulator</strong>s, <strong>Oxygen</strong>Manifold.These changes will occur in February 2011 in NSW/ACT and June 2011 in VIC/TAS.Please take the opportunity to complete the follow ing form and fax to us on (02) 8338 9797 for NSW/ACTcustomers and (02) 9364 7482 for VIC/TAS customers or place an enquiry on our website at:www.airliquidehealthcare.com.au1. Your equipment:o How many Bull Nose <strong>Oxygen</strong> <strong>Regulator</strong>s do you own ?………………….o How many <strong>Oxygen</strong> Manifolds do you own ?............................................2. Our solutions: (please tick)o Contact me to assess my needs for <strong>Oxygen</strong> Manifold Upgrade and Alarm Panel reviewo Send me a quote for new Pin Index <strong>Oxygen</strong> <strong>Regulator</strong>so Send me some information about PRESENCE Integrated Cylinders (flowmeter and <strong>Regulator</strong> in one)3. Your detailsCustomer NameCustomer NumberPhone :Email:Fax:Date:Address:AIR LIQUIDE <strong>Healthcare</strong> Pty. LtdUnit 5/476 Gardeners Road,Alexandria NSW 2015Toll free 1300 36 02 02www.airliquidehealthcare.com.auAIR LIQUIDE <strong>Healthcare</strong> Pty. Ltd40 Bunnett Street,North Sunshine VIC 3020Toll free 1300 36 02 02www.airliquidehealthcare.com.au
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