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COPD Patient Education Kit Order Form   

First Name:*
Last Name:*
Company Name:*
Phone Number: * ext.
Fax Number:
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Billing Information:
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City:* State: * Zip:*


Shipping Information (if different):

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Item Selection:

Stock No. Description Price Each* Quantity
101-M COPD Kit English $19.95

Stock No. Description Price Each* Quantity
S101-M COPD Kit Spanish $19.95

*Applicable shipping and tax will be added to your invoice.

If you belong to an ownership or voluntary group purchasing organization, you may be eligible to receive special pricing. Call a Briggs Representative for details.