Customer name

NPI Number

Ship to Address

Bill to Address (If different)

AP Contact Name

AP Contact Email

AP Contact Phone

Other emails to receive invoices (if needed)

Name and Email Authorized to sign a contract on behalf of this practice

Billing Type

Consignemnt

Direct Puchase

Please note consignment accounts require quarterly inventory reconciliations. Direct purchase accounts are invoiced based on ship date.

PO Required for Shipping

Yes

PO for Billing

Customer Provides PO

Patient ID/Date of Shipment

Patient ID/Date of Service

Other

Sales Rep Name

Distributorship Affiliation for Rep

Breeze Medical terms and conditions can be found at: https://www.breezemed.net/terms-and-conditions Please include any additional email contacts for invoices/statements, or any additional account notes below:

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