7740 Records St. • Indianapolis, IN 46226 • (317) 545-6196 • 800-428-1610 • Fax (317) 543-3289 • www.giopelle.com
LGPM01 04 09
GP-IM-CAP-90
Fast Cut Aluminum Oxide Crystals
GP-IM-CAP-100
Aggresive Aluminum Oxide Crystals
GP-IM-CAP-120
Normal Aluminum Oxide Crystals
GP-DMT-0
Disposable MassageCrystal-Free Tips
GP-DCFT-1
Disposable Course Crystal-Free Tips
GP-DCFT-3
Disposable Medium Crystal-Free Tips
GP-DCFT-6
Disposable Fine Crystal-Free Tips
GP-DCFT-HP
Handpiece for Disposable Crystal-Free Tips
GP-DCFT-T
Tubing for Disposable Crystal-Free Tips
GP-AHP-1B
Reusable Blue Nozzle for use with Crystals
GP-RT5
Disposable Tubing for use with Crystals
GP-IM-FIL-1
Gio Peel
Filter
GP-IM-CAN-1
Filter Canister
GP-IM-ORG-1
Vacuum Post O-Rings (10 per pkg.)
GP-IM-SEA-1
Filter Canister O-Ring (6 per pkg.)
Item No.
Product
Price
TOTAL
Qty.
Order No.
Date of order
GIO PELLE ORDER FORM
Sales Rep.
Initial Order
❏
Yes
❏
No
Gio Pelle
Special Instructions:
Sub Total: $
Sub Total: $
TOTAL :
Account No.
Customer P.O.#
Attn.
SHIPPING CHARGE INFORMATION: Shipping charges are prepaid by Gio Pelle and added to customers bill. *SALES TAX INFORMATION: Indiana customers add 6% sales tax to total.
Large shipments requiring inside delivery and trash removal are subject to additional charges. Equipment, accessories and prices are subject to change without notice.
Account/Physician’s Name
Speciality
Person Responsible for Purchasing Supplies/Equipment
Job Title
Address
Suite
City
St.
Zip
Phone No.
Fax No.
Name
Phone
Address
Suite
City
St.
Zip
Credit Card:
❏
Am Ex
❏
MasterCard
❏
Visa
Card Holder
Exp. Date
Card No.
CUSTOMER INFORMATION/BILL TO
PAYMENT INFORMATION
SHIP TO
❏
Check here if same as bill to address