HealthCheckSystems

Billing Address
(As shown on your credit card statement.)
First name * Last name * Company Name Address * Address2 City State\Province: * Zip/Postal Code * Country * Day Phone * Cell Phone Fax Email *
Shipping Address
First name * Last name * Company Name Address * Address2 City * State\Province * Zip/Postal Code * Country * Day Phone * Cell Phone Fax
Payment Info
Name on card * Credit Card number * CVV *

Month *(12) Year*(2025)

Visa MasterCard Amex Discover

Quantity	Name		Price EA	Total

1	Adaptive Star PXAK-1801 Phoenix Swivel Wheel Kit SKU: PXAK-1801 In Stock - Ships within 24 hours		$352.99	$352.99

1	Convaid CX14 900490-903759 Cruiser Cordura 30 Degree Fixed Tilt Wheelchair - Pink SKU: 900490-903759 Out of Stock		$1,876.00	$1,876.00

		Ground, UPS	$31.00	$31.00


			Total	$2,259.99