:: PAIN PRODUCTS INTERNATIONAL ::

Custom Tray Request Form

You can submit your request for a custom tray two simple ways: 1. Fill in the quantity for the desired accessories and click the submit order button at the bottom of the screen or 2. Print out the form, fill it out and fax to (210) 614-2080. A Pain Products International Representative will contact you to explain the complete process of creating a custom tray and answer any questions you may have. *Required fields
Business Name*
Contact's First Name*
Contact's Last Name*
Street Address
City
State/Province
Zip Code/Postal Code
Country
Phone Number*	Ext. e.g. 555-555-5555
E-mail Address

Drapes & Towels
Accessories
Fenestrated Drape	Qty
Disposable Paper Towels	Qty
O.R. Linen Towels	Qty

Solutions
Accessories
5 ml Ampule 1% Lidocaine	Qty
10 ml ampule .9% NaCl	Qty
PVP Solution 4 oz.	Qty
Iodophor PVP Sol. 1 oz.	Qty
Isopropyl Alcohol 1 oz.	Qty
Iodophor PVP Ointment 1 gram	Qty

Swabsticks
Accessories
Alcohol Swabsticks (3)	Qty
Iodophor PVP Scrub Swabsticks (3)	Qty
Prep Sponge Sticks	Qty

Gauze
Accessories
2" x 2" 12-Ply Sterile	Qty
3" x 3" 12-Ply Sterile	Qty
4" x 4" 12-Ply Sterile	Qty

Prep Tray Components
Accessories
Sterilization Pouch	Qty
CSR Wrap	Qty
Procedure Tray	Qty
Prep Tray	Qty
Medicine Cups (60cc)	Qty
6" Clear Plastic Ruler	Qty
Surgical Marker	Qty
Microbore Extension Set	Qty
1" x 3" Bandaid	Qty

Syringes
Accessories
3CC Luer Slip	Qty
3CC Luer Lock	Qty
5CC Luer Slip	Qty
5CC Luer Lock	Qty
10CC Luer Slip	Qty
10CC Luer Lock	Qty
10CC Control Syringe (Luer Lock)	Qty
20CC Luer Slip	Qty
20CC Luer Lock	Qty
20CC Control Syringe (Luer Lock)	Qty
30CC Luer Slip	Qty
30CC Luer Lock	Qty


	Phone: Toll Free- 1-800-359-5756 or (210) 614-2062 Fax: (210) 614-2080	©pain products international 2003. All rights reserved. HUB Certified.