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	Convaid EZ12 EZ 900860-903465 Rider 10 Degree Fixed Tilt Special Needs Stroller - Purple SKU: 900860-903465 Out of Stock		$1,418.40	$1,418.40

1	Convaid CX12 902845-903855 Cruiser Cordura 30 Degree Fixed Tilt Wheelchair - True Red SKU: 902845-903855 Out of Stock		$1,876.00	$1,876.00

1	Edushape 806050 Edu Blocks SKU: 806050 In Stock - Ships within 24 hours		$162.00	$162.00

		Ground, UPS	$25.50	$25.50


			Total	$3,481.90