Intera Oncology | Order Form

Billing Information

Account/Company Name *

Company Address 1 *

Company Address 2

Department Name *

City *

State *

Zip code *

Tax ID

Tax Exempt? *

Email address for electronic invoices *

If you are a tax exempt facility or reseller/distributor please forward your tax-exempt form or resale certificate to: accounting@interaoncology.com

Billing Contact Name *

Contact Title *

Email *

Contact Phone Number*

Contact Fax Number *

Ship to: Account Name *

Contact Name*

Contact Email *

Contact Phone Number*

Address 1 *

Address 2

City *

State *

Zip code *

Ship to: Account Name

Contact Name

Contact Email

Contact Phone Number

Address 1

Address 2

City

State

Zip code

* These fields are required.

If you have more than two locations to ship to, please fill out the excel file and email to accounting@interaoncology.com

If you have questions or require additional information (W-9, Tax ID, ACH information), please email accounting@interaoncology.com

To place an order, please call: 800-909-4518 - Fax: 888-664-0080 - Email: interaoncology-us@healthlinkeurope.com