OHSU Student Center -Order Forms

At this time payments for Medical Equipment orders can only be processed via phone or in person. Please call us toll free: 877 342-3907 or local: 503 494-7708 or if you prefer we can call you. Please fill out the form below and mark the box as to your preference. If you have ordered from us recently, we may have the card number on file. Thank You!

Date:

mm/dd/yy

First Name:

Middle Initial:

Last Name:

Degree:

E-mail:

Acknowledgment and receipt of order will be sent via e-mail.

What would you like us to do when your order comes?:

Inform you via E-mail?

Call you?

Ship it to you?

If you would like us to call you when the order comes, please provide a phone number where we can contact you

Telephone Number:

If you would like us to ship the order, please provide your address

Address 1:

Address 2:

City:

State:

Zip Code:

Please check appropriate box

Credit Card Information:

You have ordered from us and we have your Credti Card#

You will call with Credit card #

You want us to call you for Credit Card #

If you would like us to call you for the Credit Card #, please provide a phone number where we can contact you

Phone Number:

Order Information

Equipment Categories:

Stethoscope

Blood Pressure Kit

Pen Light

Tuning Fork

Reflex Hammer

Misc Medical Equiptment

Special Order

Please list Manufacturer or Model Numbers:

Questions or Comments on your order:

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