LASER SUPPLIES ORDER FORM Complete - Print - Fax (949) 486-0586
Dr. Mr. Ms. / Last Name		Business
First Name		Ship to
.	.	City
Telephone with Area Code	FAX	State	Zip
Email
Indicate product choice by filling in quantity ordered.
///PHARMACEUTICAL CRYOGEN		Quantity
680gm /// $25 /canister			Sold in Case (12 can) Lots
1000gm /// $29 /canister			Sold in Case (12 can) Lots
///VALVE //	/ $18 /valve		(for emptying canister)
///SAPPHIRE LASER WINDOWS	$10 ea.
	///25+//$9 ea.		Volume Discount
	//50+//$8 ea.		Volume Discount
///O-RINGS FOR WINDOWS/	// $ .25 ea.		White Silicone
///DISTANCE GAUGE KITS	$35 ea.		.
Distance Gauge Base/// $15 ea.			.
///DISTANCE GAUGE ///TREATMENT RINGS	$1.50 ea.		.18mm
	.		.15mm
.	.		.12mm
///ADJUSTABLE SLIDER	$450		12-15-18mm
(Price includes $50 deposit with refund upon return.)/
///FLASH LAMPS	GentleLase Flash Lamps//$475 ea.		.
	V/Beam Flash Lamps//$750 ea.		.
Replacement Fiber Optics for GL//$725			.
Re-Built Hand Piece///$350			Call for details.
UPS SHIPPING OPTIONS
GROUND (most economical) 3 Day Select 2nd Day Air Next Day Air Saver
Please Complete - Print - Fax (949) 486-0586. Thank you for ordering from Kool Blast. Close out window to continue -- after printing form..