DaVita Nurse Call Order Form – TeleVision Hospital Products

Facility Name & Unit # *

ATTN. Name: *

Facility Phone # *

Coupa PO # *

Per DaVita Policy, all requests for service will now have to a Coupa PO number created to allow us to transact, so we may invoice against it. Thank you.

Email *

Email

Confirm Email

Pillow Speaker Model # & Type of TV

Patient Stations Model #

Number of Call Cords

Amount of Pillow Speaker Units

Amount of Patient Station Units

Box of 100 Earbuds (min order 100 per box)

Delivery Shipping Options *

Ask about a Overnight Rush Shipping quote before ordering.

Misc:

Quote Price Request

If you have any questions on availbility or delivery tIme please call or contact the office at (949) 244-1235

Additional Comments