Contact Name:
Contact Phone:
Hospital/Organization:
Billing Address:
Billing City:
ST
Zip
Pick-Up Address:
Pick-Up City:
Department:
Pick-Up Department:
Level of Service Desired:
By the Apron: $50 per Apron plus shipping, your packaging, contents suitably wrapped in plastic bag
30 Gallon Barrel (we’ll ship one to you)
$400.00 plus shipping.
55 Gallon Barrel (we’ll ship one to you)
$900.00 plus shipping.
PO#
Lead Apron Service Order
This Form is designed to be printed and faxed to us (513-242-5059). Remember, in order to process this request for service, you need to fax your physicist's letter of certification along with this form. The data in this form is not being saved on our server.