Customer Order Form

1. Select your state in the option menu under the "Online Ordering" tab.

2. Choose the type of service needed.

3. Fill out the required information:

• State
• Hospital name
• Service requested
• Patient name
• Room number
• Purchase Order # or MR #
• Nurse contact name
• Email and phone number

4. Review your request, then click "Send."

Upon order submission, you will see a confirmation message on your screen and receive a digital receipt of your request via email. A Vivax Medical representative will contact you with an estimated time of arrival (ETA).

If you have any questions, please call us anytime at (866) 927-7747 or email SomaSafe@vivaxmedical.com.