POB Booking Form

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POB Booking Form

Provide precise details for the Purchase Order Booking.

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CLINIC / DOCTOR DETAILS

Doctor Name *

Dr.

Clinic / Hospital Name *

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Full Address *

City *

State *

Mobile No. *

+91

Email ID *

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STIMULATION DATA

Average no of Stimulations done per Month *

Cycle < 20/Month check_circle Cycle > 20/Month check_circle Cycle < 50/Month check_circle Cycle > 50/Month check_circle

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ORDER DETAILS

Product

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Quantity Required (Units)

Special Requirement / Remarks

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COMMERCIALS

Cost of Device ₹ 15,000 /-

Cost per Pack ₹ 1,500 /-

Tentative Dispatch Timeline

schedule Within 72 hrs of billing

I hereby confirm my interest and order booking for NFIS device(s) under ISAR launch offer.I understand that allotment is subject to availability and will be on first-come-first-served basis.

INTAS Representative Name *

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Orders will be processed on first-come-first-served basis.