Americana Corporation Rehab Software

Order Forms

Welcome to our Forms Order page. Our system utilizes special forms that can be ordered directly from us for use and re-stocking. Please fill out the order form below by specifying which facility you're with, select the forms you would like to order and specify the quantity as the number of boxes.

Please fill in ALL required (*) fields below, and as always, thank you for your business.

Today's Date: 12/18/2017
Facility Name: *  
4 digit Facility ID: * (whats this?)
Shipping Address: *
City: *
State: *
Zip: *
Phone Number: *
Customer Name: *
Customer Title:
Customer E-mail: *
Customer PO or Memo:

 


Product # Form Name Qty per Case Cost per Case # of Cases Total
2001-L Physician Orders Forms 1000 $89.00 $
2003-L Medication Forms 1000 $77.00 $
2004-L Treatment Forms 1000 $77.00 $
2005-L MISC Forms 1000 $77.00 $

Total Quantity:
Order Total:

(Note: This order will be processed by our staff.
No credit card or billing information is required)

(Please allow for Shipping and applicable taxes)

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Links:
American Healthcare AssociationCenters for Medicare & Medicaid ServicesVision ShareAmerican Payroll Association

Nursing Home Software