800.879.4755  UNITED STATES
913.217.7160 INTERNATIONAL

Order Form
For RenaPlex®, RenaPlex®-D, MagneBind® 300 and Calphron®
Please enter all information, print the form and mail to
Nephro-Tech, Inc., P.O. Box 16106, Shawnee, KS 66203

First Name Last Name
Mailing Address
City State Zip Code
Phone
(Please include area code)
Call 1.800.879.4755 for case pricing information.
PRODUCT COST QUANTITY TOTAL
RenaPlex® $9.00 per bottle (100 tablets)
RenaPlex®-D $12.00 per bottle (100 tablets)
MagneBind®300 $15.75 per bottle (150 tablets)
Calphron® $15.00 per bottle (200 tablets)
SUBTOTAL:
Prior Balance: (Overpaid -) Underpaid + -/+
Kansas Residents Only - Multiply subtotal by .08 for sales tax +
Shipping and Handling (per order, not per bottle) $4.95
TOTAL COST OF ORDER:
If paying with a check or money order, make payable to Nephro-Tech, Inc. If paying with a credit card, call 800.879.4755 OR complete the information below:
Credit Card # Exp. (mo/yr)
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