May 11, 2008

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Catalog Request Form Would you like a copy of our 2008 Buying Guide for your office? If so, please supply the necessary information below. Please allow 2-4 weeks for delivery within the United States and 6-8 weeks for international requests. Note: Our website is the best place to find current pricing and product information. required fields are bold Physician's Name: Institution or Practice Name: Medical Specialty: Please Specify...Allergy/ImmunologistCardiologistChiropractorClinicDentistDermatologistEmergency Room PhysicianEndocrinologistFamily PractitionerGastroenterologistGeneral PractitionerGovernment/Military FacilityHospitalInfectious Disease SpecialistInternal MedicineLaboratoryMedical LaboratoryMedical Supply DealerNurse (ARNP/NP/RN)Obstetrician/GynecologistOphthamologistOral Maxillofacial SurgeonOrthopedic SurgeonOtolaryngologistPediatricianPharmacyPhysician Assistant (PA)Plastic SurgeonPodiatristPsychiatristSurgeonUniversity/Medical CollegeUrologistVeterinarianMedical Specialty Not Listed License Number: Address: City: State/Province: Country: Zip/Postal Code: Phone Number: Person Requesting: Email Address:

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PHYSICIAN CATALOG / OVERSTOCKS / CUSTOMER SERVICE / MY ACCOUNT SHOPPING CART / MSDS INDEX Delasco   608 13th Ave.   Council Bluffs, IA USA 51501-6401 voice: (800) 831-6273   (712) 323-3269 fax: (800) 320-9612   (712) 323-1156 questions@delasco.com