Cerapedics · Delivered Order Form

New i-Factor bill

Labels and patient details stay in browser memory. Download or share the PDF before closing this page.

1. Add patient and product labels

Upload photos or PDFs, including photos containing both labels. Review the separated crops below.

2. Case details

Hospital / facilityDate of surgerySurgeonPatient ID / MRNPO number

Use confirmed HonorHealth pricing

1.0cc $600 · 2.5cc $1,450 · 5.0cc $2,800. Only select for an HonorHealth case. Changing this selection resets all unit prices; other facilities require manual pricing.

Additional billing and shipping fields

Billing hospital IDBilling addressBilling city, state, ZIPBilling phoneShip-to facilityShip-to hospital IDShip-to addressShip-to city, state, ZIPShip-to phoneSurgeon contact

CAS Advisors · Distributor 3268 · Christy Schaffer · 7013210424 · Inventory source: CAS

3. Products and charges

Verify quantity against the products used. Leave unknown prices empty. Each row records one product code and lot.

Total: Awaiting complete pricing

4. Review and generate

I checked the patient, facility, surgeon, surgery date, product codes, lots, quantities, prices, and possible duplicate labels. Blank fields are intentionally unknown.

Unknown fields and signatures stay blank. Multiple lots of the same product create additional forms with separate totals.