Western Systems Research, Inc.

ACCESSORY REORDER FORM

Name and address: Purchase Order Number:

Date of order: ______

______Phone number:

Fax number:

PRODUCT DISCRIPTION / MODEL NUMBER / LIST PRICE /

QUANTITY

/

TOTAL PRICE

Duotrode Electrodes / 7 Pkg of 17 electrodes (22 Tests) / $74.00/box
Huggables Electrodes / Case of 600 electrodes (120 tests) / $175.00/case
Huggables Electrodes / Box of 30 electrodes (6 tests) / $15.00/box
Electrode Harness / EH-1 (VAT) / $295.00/harness
Electrode Harness / EH-2 (ENG) / $295.00/harness
USB Serial Adapter / CC-USB-SER / $150.00/ adapter
Prep & Stay / Prep & Stay (3400-15) / $12.00/bottle
Signa Gel / Signa Gel for electrodes (15-25) / $15.00/tube
Tape Measure / 72” round tape measure (inch and metric) (84029) / $7.00/ tape measure
Surgical Tape / 1”x10yards. 12 rolls/box (1538-1) / $24.00/box
Alcohol Prep Pads / 2 ½”x1 ¼” pads 200 pads / box (B60307) / $11.00/box
Surgical Scissors / 4 ½” Steel Surgical Scissors (48006M) / $11.00/each
Gauze Squares / 2x2 12 ply gauze pads 100/box (3381) / $18.00/box
Surgical Caps / Disposable Caps 100/box / $30.00/ box
Power Cord / 10’ UL approved hospital grade power cord (115078CD) / $30.00/each
Head Strap / Hs-004 / $95.00/each
VAT and ENG Test Administrator’s Manual / John Coverstone / $225.00/manual
Extension Cable for VAT/ENG / QV-90k9 / $38.00
Power Supply / PS-100 / $285.00

Revised: 04-07-2015 Form 5000 V.1

Ordering Options

1)  Email order forms to:

2)  Fax Order forms: 951-302-2976

3)  www.4wsr.com online store

Shipping prices will vary, depending on weight and destination of package. Orders submitted before 3pm PST will be shipped that day. Orders submitted without a shipping method selected will go out UPS Ground.

SHIPPING: UPS Overnight  2nd Day  3rd Day  Ground 

32605 Temecula PKWY. Suite 316 / Temecula, CA 92592
Voice: 951-302-2977 or 1-800-701-7078 / FAX: 951-302-2976
Website: www.4WSR.com

FD-MD-Agi-ClientAccessoriesPriceList