Use this form to order via Fax, Phone or Postal Service
No information entered on this form will be sent over the internet.
After completing this form, use your browser's print button to print the form.
For online order form click here. For NeuroTek home page click here.

Printable Order Form *Indicates required fields
                        FOR U.S. ORDERS  NO POST OFFICE BOXES PLEASE
*Clinician's Name
*Address:
Address:
*City,State,Postal:
*Email address:
*Area/Country code & phone: *Country:
Check if you have ordered from us before?
*Date and place of most recent EMDRIA approved training:
*Name of EMDRIA approved instructor:

*Quantity: *Item: Unit Cost: Ext. Cost:












Additional items not on choice list






Order Sub-total:
Note: Non U.S. orders - If ordering EyeScan, LapScan or AC adapters, please specify AC Adapter type in comments section
(See international page for more information)
Indicate desired shipping method:
NeuroTek will add or adjust shipping & handling charges if necessary.
If shipping to a U.S. residence, check this box
UPS and DHL charge extra to deliver to a residence even if it is a business in your home, apartment or any structure resembling a residence or in a residential area.
Estimated Shipping & Handling:
NeuroTek will add sales tax if applicable:
Estimated Order Total: USD
Credit Card: Expires: 
Comments:
After completing, use your browser's print button to print the form.
Top of form
NeuroTek accepts MasterCard. NeuroTek accepts  Visa cards. NeuroTek accepts  American Express.