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MEEI
Hearing Aid Center Mail Order Battery Form
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Note: This form is
for Mail Order
Massachusetts Eye and Ear Infirmary
243 Charles Street
Boston, MA 02114
617-573-4047
Please make checks payable to: MEEI - Hearing Aid Center |
Patient Name_____________________________________________________
Patient Address_____________________________________________________
Patient Telephone Number_____________________________________________________
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| BATTERIES |
| size |
package price |
quantity |
total |
| 10 |
$5.00 |
4 pack |
|
| 312 |
$5.00 |
4 pack |
|
| 134 |
$5.00 |
4 pack |
|
675
|
$5.00 |
4 pack |
|
| |
| 10 |
$9.00 |
8 pack |
|
| 312 |
$9.00 |
8 pack |
|
| 134 |
$9.00 |
8 pack |
|
675
|
$9.00 |
8 pack |
|
| BATTERY
COUPON BOOKS |
| size |
package price |
quantity |
total |
| 10 |
$30.00 |
7-4 packs |
|
| 312 |
$30.00 |
7-4 packs |
|
| 134 |
$30.00 |
7-4
packs |
|
675
|
$30.00 |
7-4 packs |
|
| |
| 10 |
$56.00 |
7-8 packs |
|
| 312 |
$56.00 |
7-8 packs |
|
| 134 |
$56.00 |
7-8 packs |
|
675
|
$56.00 |
7-8 packs |
|
| ADHEARS
CERUMEN GUARDS **** |
| |
|
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Signature |
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Date |
| date of form:
May 7, 2003 |
