Order Verification and Approval Form

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Order Verification and Approval Form

Please review the information below carefully, including the attachment(s). Select your delivery option and ensure all yellow boxes are complete and accurate. Failure to complete form may cause shipping delays.
**MWI Representative** Internal Use information is collected at the bottom below the submit button
Please confirm shipping address, Email, & phone number

*To be completed by customer/authorized agent
Business Name
Clinic Address

Ship-To Address

Street Address Line 2

CityState

Zip Code
Clinic Email Address
Clinic Phone Number

Area CodePhone Number
Notes
Required field. If attachment is provided type 'See Attachment'
Midmark Documentation (customer pricing)

Browse Files

Cancelof
I verify that I have reviewed the items provided and they are correct and complete.
Enter your initials
Select delivery option (via trucking company, not available with UPS)

Lift Gate Only- Truck with a lift gate will deliver product, no driver assistance. Clinic is responsible for unloading product from the truck lift gate and moving product inside by themselves. Customer will need to note if the location has a loading dock, forklift, and/or pallet jack, this equipment will not be provided. Clinic is responsible for any damages that may occur during the unloading processes
White Glove Delivery – Below charges in addition to line haul charge to destination:
- Delivery equipment includes lift gate-equipped truck, pallet jack and hand truck.
- Two (2) delivery personnel always provided.
- Inside delivery to a room of choice on ground floor.
- Includes up to 30 minutes of service for 1000 lbs. of freight, for Off-loading, de-skidding, placement and debris removal to an off-site receptacle. (No Assembly).
- Do not interrupt or delay process as additional charges will apply.
- White Glove Delivery personnel are not to move existing equipment or furniture within clinic.
Initial Here to acknowledge white glove delivery selected.
Enter your initials
Would you like to request a call from the freight company to schedule your delivery?
Please provide your contact information below. This will be used by the freight company to schedule your delivery.
Contact Name

First NameLast Name
Contact Phone Number

Area CodePhone Number
Is this a new opening practice project?
Please specify date you can start receiving equipment.

MonthDayYear
Midmark Freight Storage based on the Scheduled Ship Date

If you can not receive when Midmark is ready to ship:

- Customer freight will be stored on Midmark's dock at no charge for the first week, however, subsequent weeks will have a fee.
- Less than a Truckload (LTL) $500.00 per week
- More than a Truckload $700.00 per week, per truckload
Can you accommodate a full size delivery truck?
Delivery Restriction Explanation
I agree to inspect delivery before I sign for the product. If I do not inspect the product and sign for product without noting any damages, I assume liability for any damaged product. It would then be my responsibility to contact the freight company and file a claim with them.
Enter your initials
Initials provided do not match.
- Order ID Number (if available)
  From Midmark Documentation
- MWI Account Number
- Clinic Name
- Customer/Authorized Agent Email Address
- Customer/Authorized Agent initials required. Not to be initialed by MWI representative.
- MWI Rep Email Address
- MWI CER Email Address
- Should be Empty: