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Order Request Form

To request an order please fill out the form below. If you have any questions or comments about your order please add them to the Additional Notes/Message section at the bottom of the form. All orders are shipped out upon receipt of payment via UPS ground. Expedited shipping requests are available at the customer’s expense.

Shipping is available in the United States and Canada only. Canadian residents are responsible for any customs/exchange fees upon delivery.

Revolution EHR Ordering Form

Customer Information

Contact Name
Contact Name
First
Last
Billing Address
Billing Address
Address 1
Address 2
City
State/Province
Zip/Postal
Country
Check this box if your Shipping Address differs from the Billing Address listed above
Shipping Address
Shipping Address
Address 1
Address 2
City
State/Province
Zip/Postal
Country

Available Products

Please note that due to 3rd party product privacy, prices are not listed below but are available upon request. Otherwise, they will be listed on your e-invoice.

Please select the products you wish to order below. 
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1 roll = 1,333 labels | 3 rolls = 4,000 labels
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1 roll = 800 labels | 5 rolls = 4,000 labels
Add Product
1 roll = 800 labels | 5 rolls = 4,000 labels
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