Practice/Facility Name: Invoice Attention To: Address: City/town: Zip code: SHIP TO: (If different from above) SHIP TO ATTENTION: SHIP TO NAME: Address: Ship to Fax #: Ship to Phone #: Ship to Email: CONTACTS: Doctor's Name: Purchasing Name: Doctor's Phone #: Purchasing Phone #: Doctor's Fax #: Purchasing Fax #: Doctor's Email: Purchasing Email: Radiology Name: ACCTS Payable Name: Radiology Phone #: Accts Payable Phone #: Radiology Fax #: Accts Payable Fax #: Radiology Email: Accts Payable Email: Tax Empt? YesNo IF YES, PLEASE UPLOAD A COPY OF THE TAX EXEMPT CERTIFICATE Enroll In Paperless Invoicing & Statements YesNo If yes, email address:
