Grover Gear Medical
13425 Morgan Ave S
Burnsville, MN 55337

FAX: 952-808-8587
Phone: 866-666-9680
 Bill To:
Name                                                                       
Address                                                                                
City, State, Zip                                                                     

Ship To:                                                                             
(if different)                                                                             
Phone:                                                                                   
Email:                                                                                    
Date:                       
PO#                         
Quantity
Item
Number
Item Description
Price
Total Price
         
         
         
         
         
Sub Total
  
Tax (MN only:
7.125%)
  
Shipping (see
chart to left)
  
Total
  
Shipping
Standard flat rate Shipping charges are based on dollar amount of
Purchase Orders.  Rates apply to continental United States.  Contact
us for expedited or International Purchase Order rates.
Credit Card Payments

Card Type _________

Card Holder Name                                           

Card Number _______________________  

Expiration Date ____/____        

Card Verification Code - 3 Digits on back of card ______
Purchase Total
 Shipping Cost
$15.00 - $44.99
 $8.00
$45.00 - $124.99
 $14.00
$125.00 - $249.99
 $25.00
$250.00 - $449.99
 $35.00
$450.00 - $999.99
 $75.00
$1000.00 and Up
 $100.00
Printable Order Form
  • To place an order by FAX, print and fill out the form below and FAX it to 952-808-8587.  
  • To place an order by mail, print and fill out the form below and mail to the address below.
  • All FAXED and mailed orders will be acknowledged via phone or email within 24 hours of receipt.  
  • If you have a question about the form, please call or email us and we'll be glad to assist you!