MBO ACCOUNT SETUP FORM - Florida Medical Sales
MBO ACCOUNT SETUP FORM - Florida Medical Sales
MBO ACCOUNT SETUP FORM - Florida Medical Sales
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>MBO</strong> <strong>ACCOUNT</strong> <strong>SETUP</strong> <strong>FORM</strong><br />
Please complete highlighted fields. Fax forms to: 866-308-0915 Email forms to: admin@floridamedicalsales.com<br />
Account Help Line call 888-269-1810<br />
QTY Requested Product Code Description QTY Cost<br />
FENT50 **Fentanyl citrate 50 mcg/ml PF - 25x2ml PK $200.00<br />
MORPF-10 **Morphine 1mg/ml PF - 10ml 10x10ml PK $135.00<br />
ATP04 Atropine sulfate 0.4mg/ml PF - 1ml EA $17.00<br />
B12SP4-30 Cyanocobalamin 1000mcg/ml - 30ml EA $23.00<br />
BUP25 Bupivacaine 0.25% (preserved) - 50ml EA $21.00<br />
BUP50PF Bupivacaine 0.5% PF- 30ml EA $21.00<br />
BUP75PF Bupivacaine 0.75% PF - 30ml EA $26.50<br />
DEA Dehydrated Ethyl Alcohol 98% 1ml EA $17.00<br />
VAL1010 Diazepam 5mg/ml - 10ml EA $15.50<br />
VAL102 Diazepam 5mg/ml - 2ml EA $9.00<br />
ETM40 Etomidate 40mg SDV - 20ml EA $45.00<br />
FUR404 Furosemide 10mg/ml - 4ml EA $15.00<br />
EH101 Hyaluronidase 150units/ml PF - 1ml EA $18.00<br />
EH102 Hyaluronidase 150units/ml PF - 2ml EA $27.00<br />
KETSP30 Ketorolac 30mg/ml - 1ml EA $8.00<br />
KETSP60 Ketorolac 60mg/2ml - 2ml EA $10.00<br />
LIDO1 Lidocaine 1% (preserved) - 50ml EA $12.75<br />
LIDOPF1 Lidocaine 1% PF - 30ml EA $15.25<br />
LIDOPF2 Lidocaine 2% PF - 30ml EA $15.50<br />
LIDO4MPF Lidocaine 4% MPF - 5ml EA $13.00<br />
MAG501 Magnesium sulfate 50% SDV - 10ml EA $15.00<br />
MAG505 Magnesium sulfate 50% SDV - 50ml EA $45.00<br />
MANN25 Mannitol 25% PF - 50ml EA $27.50<br />
METSP5 Metoclopramide 5mg/ml - 2ml EA $8.00<br />
MID105 Midazolam 1mg/ml MDV - 5ml EA $13.50<br />
MID510 Midazolam 5mg/ml MDV - 10ml EA $31.00<br />
NAC20SP Acetylcysteine 20% PF - 4ml EA $10.50<br />
NAL101 Nalbuphine 10mg/ml PF SDV - 1ml EA $8.50<br />
ONSP2 Ondansetron 2mg/ml PF - 2ml EA $9.00<br />
OXY10 Oxytocin 10units/ml PF - 1ml EA $7.50<br />
SC120 Succinylcholine 20mg/ml - 10ml EA $32.00<br />
SBC84 Sodium Bicarbonte 8.4% PF 50ml EA $21.00<br />
**Requires DEA 222 or CSOS<br />
These items will only be compounded during manufacture backorder status and have a 3-5 month expiration<br />
All items are tested by a DEA & FDA registered lab before shipped - see our microbiology reports<br />
See page 2 for account setup
Rep Name<br />
Rep Email<br />
Rep Cell<br />
Purchase Order<br />
Facility Name<br />
Contact for Shipment<br />
Street<br />
City, State, Zip<br />
Email (tracking info)<br />
Physician Specialty<br />
Phone Number<br />
Fax Number<br />
*Physician Full Name<br />
*DEA #<br />
Ship To:<br />
*Physician name & DEA is required to be on file for all RX shipments<br />
Ordered items not returnable / Freight charges applied to overnight orders<br />
Purchase Order<br />
Facility Name<br />
Contact for Shipment<br />
Street<br />
City, State, Zip<br />
Email (tracking info)<br />
Physician Specialty<br />
Phone Number<br />
Fax Number<br />
*Physician Full Name<br />
Account Setup Form<br />
Please complete highlighted fields. Fax forms to: 866-308-0915 Email forms to: admin@floridamedicalsales.com<br />
Account Help Line call 888-269-1810<br />
Bill To If Different:<br />
Instructions for editable PDF: Type into fields and then "save as" a file on your computer. Email new file.<br />
To Fax simply type into the fields and then print from your computer. Fax to 866-308-0915.
Change language