Online Order Form

Welcome to Knueppel HealthCare Online! If this is your first online reorder with Knueppel HealthCare Services, Inc., we need a little information from you. Please complete the following form.

If you are a new client and have never worked with Knueppel HealthCare Services, Inc., please contact us directly by calling 414-258-2800 or 800-942-6422 for your first order.

Required Field*

Client Information

First Name*

Last Name*

Daytime Phone*

Format: 999-999-9999

Home Phone

Format: 999-999-9999

E-mail Address*

Billing Address

Street*

City*

State* Zip*

Shipping Address

Same As Billing

Business Name

Street*

City*

State* Zip*

Payment Information

I will pay for the order using my credit card.

	Card Type*
	Card Number*		No dashes
	Name as it appears on card*
	Expiration Date*

Please bill my insurance provider.

Please review and update insurance information frequently.

Primary Insurance:

	Company Name*
	ID Number*

Secondary Insurance:

	Company Name
	ID Number

Prescribing Physician:

	First Name*
	Last Name*
	Office Phone*		Format: 999-999-9999

Product Information

Please list all products being reordered.

Manufacturer	Product Number	Description	Size (If applicable)	Color (If applicable)	Qty

Comments

Pick-up/Delivery Information*

I will pick-up my order at:

	1444 S. 113th St., West Allis
	1143 Warwick Way, Racine
	7400 W. Rawson Ave., Suite 140, Franklin
	10510 N. Port Washington Road, Mequon
	Orders placed by 2:00 p.m. will be ready for pick-up by 9:00 a.m. the following business day. Orders placed after 2:00 p.m. will be ready for pick-up after 11:00 a.m. the following business day. Please see below for contact information and store hours.

Please ship my order via UPS.

On-line orders are shipped free of charge for orders of $75.00 or more.
Orders placed by 2:00 p.m. will be processed the same day, Monday through Friday.
Orders placed after 2:00 p.m. will be processed the next business day.
UPS deliveries for in-stock products are usually received within 2-3 business days of ordering.

Questions or comments? Phone or email us.

West Allis: 414-258-2800 or 800-942-6422 (Hours: M, TH, F 9-5, T & W 9-6 and Saturday 9-12)
Racine: 262-321-0110 (Hours: M-F 9 a.m.-5 p.m.)
Franklin: 414-525-2600 (Hours: M-F 9 a.m.-5 p.m.)
Mequon: 262-240-1700 (Hours: M-F 9 a.m.-5 p.m.)

You can also print this form and fax it to Knueppel.
Milwaukee/West Allise fax: 414-258-2855
Racine fax: 262-321-0212
Franklin fax: 414-525-2906
Mequon fax: 262-240-1702

Note: Incomplete information may delay order processing.

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