PHONE : 1 - 866 - 262 - 2174 FAX : 1 - 866 - 366 - 5381
SECTION A - Order: (please print clearly; all prices are in USD) 
SYNVISC (Hylan G-F 20)3 X 2ml - s35900USD

   Quantity : __________ Xs35900USD =  ____________ TOTAL

SECTION B - Credit card Holder Information: (please print clearly)

Name On Card :		 ____________________ CC Company : Visa MasterCard

Card Number :		 ____________________      

Expires :

 ____________________ Signature :
 _________________________________
SECTION C - Physician Information: (please print clearly)

First Name :		 ____________________ State : _________________________________

Last Name :		 ____________________ Zip : _________________________________

Street 1 :		 ____________________ Phone : _________________________________

City :

 ____________________ Fax : _________________________________


Physician's Signature : ______________________		   Date : _____________________

DEA # : ______________________		   License # : _____________________


The physician is to fill out all required areas of this form.The Credit Card information is generally that of the patient.All orders will be shipped to your office
"care of" the patient designated in the Credit Card information.