ORDER FORM USA/International
Contents
1. 5 Bulbs UVB Narrowband 180 watts 3 Bulbs UVB Narrowband 108 watts 2 Bulbs UVB Narrowband 72 watts 100 Series Handheld Phototherapy Small wand with two 9 watt bulbs Includes carrying case and one set of six perture Plates The Positioning Arm and UV Brush for scalp psoriasis are o 2 Bulbs UVB Narrowband 18 watts 795 00 2 Bulbs UVB Broadband 18 watts 795 00 Positioning Arm Kit for 100 Series units 245 00 Oooo i E UV Brush for 100 Series 1 50 00 Spare Aperture Plates for 100 Series Set of 6 25 00 Common Replacement Ultraviolet Bulbs Shipping amp Packaging Extra Many other UV bulb types available 6ft UVB Narrowband Long length Philips 120 00 6ft UVB Narrowband FS72 or Short length Philips 120 00 Fits Solarc 500 Series UVB Narrowband Philips 105 00 Fits Solarc 100 Series UVB Narrowband Philips 45 00 sd yi PL S 9W 12 Fits Solarc 100 Series UVB Broadband Philips 45 00 C gt o v lt i P FS72T12 UVB HO Fits Solarc 6ft UVB Broadband and many others 110 00 es el Shipping For replacement bulbs beyond points Call for pricing Total Purchase US A Notes 1 The Total Purchase price is the entire amount that is payable and the only charge that will be made to your credit card This amount includes all freight customs and brokerage Solarc Systems does not collect any US or International taxes If any US or International taxes2. apply they are payable by the purchaser All devices are fully assembled with new ultraviolet bulbs 1 pair ultraviolet protective goggles comprehensive user s manual with exposure guidelines for psoriasis amp vitiligo and mounting hardware if needed There is nothing else that you need to purchase Shipping is included to most locations in continental USA Extra charges apply for Beyond Points amp International The US Department of Homeland Security requires that imports greater than US 2500 must identify the ultimate consignee using the customer s social security number SSN Please enter on page 2 if required 2013 Solarc Systems Inc Rev 9 2 USA PATIENT RESPONSIBLE PERSON INFORMATION Please print clearly Patient Name Responsible Person Name Address City State Phone Email If purchase is greater than US 2500 provide your SSN here Solarc Systems Inc Terms and Conditions of Sale for Ultraviolet Phototherapy Device The Device is defined as a Solarc SolRx Ultraviolet Phototherapy Lamp Unit or Ultraviolet Phototherapy Bulbs The Patient is defined as the person that is intended to receive ultraviolet skin treatments using the Device The Responsible Person is defined as the Patient or any person that is in care or custody of the Patient such as a parent or guardian A Healthcare Professional is defined as a medical doctor MD or nurse practitioner qua
3. obtains for the Patient a skin examination performed by a Healthcare Professional at least once per year b The Responsible Person understands that as with natural sunlight use of the Device may cause adverse effects including but not limited to premature aging of the skin and skin cancer The Responsible Person agrees that the Healthcare Professional is not responsible for any adverse effects arising from the use or misuse of the Device I FURTHER ACKNOWLEDGE AND CONFIRM that I have been advised of the implications of not following the instructions contained in the Information Document including but not limited to the possibility of undetected skin cancer or other adverse effects and I hereby indemnify and save harmless the Healthcare Professional named above with respect to any action that I may have against the Healthcare Professional named above or any of his affiliate practitioners or professional corporations should I not abide by my express obligations contained in the Information Document including but not limited to providing my current address and full contact information to such practitioner DATED at city this day of month year Witness Signature of Responsible Person
4. should the original be lost A replacement User s Manual will be supplied free of charge by Solarc Systems Inc The Responsible Person agrees that the Patient and all other persons exposed to the ultraviolet light produced by the Device will wear ultraviolet protective eyewear during Device operation The Responsible Person understands that as with natural sunlight use of the Device may cause adverse effects including but not limited to premature aging of the skin and skin cancer The Responsible Person agrees that the Healthcare Professional and or Solarc Systems Inc and or any associated reseller is not responsible for any adverse effects arising from the use or misuse of the Device For E Series Devices the Responsible Person agrees that ADD ON Devices will only be connected to and operated from a Solarc E Series MASTER Device to a maximum of 4 ADD ON Devices per MASTER Device This transaction and its terms and conditions shall be governed by the laws of Ontario and the laws of Canada applicable in Ontario Solarc Systems Inc and the Responsible Person agree to accept signatures by fax and that they shall be legal and binding understand and agree to the above Responsible Person Signature 3 Dated 3 SHIPPING INFORMATION L Same as above Name Address City State Zip Phone Email SoIRx 1000 Series Shipping Policy This is an overweight package gt 7Olbs It is not possible fo
5. HOME PHOTOTHERAPY ORDER FORM USA amp International 5 Pages Directions for Use 1 Read and understand the Terms and Conditions of Sale then complete each applicable section of the form 1515 Snow Valley Road 2 Have your Healthcare Professional MD or Nurse Practitioner complete Minesing ON LOL 1Y3 the Healthcare Professional Approval section OR attach a physician s d prescription for the device This is required for USA shipments only Toll Free 866 813 3357 Please keep copies for your records Fax 705 739 9684 24hr Fax email or mail your order to Solarc Be sure to include all applicable info solarcsystems com sides of this form Once received Solarc will acknowledge your order SolarcSystems com and provide shipping information SYSTEMS INC prs Qty Part Number Product Description Unit Price Total E720M UVBNB_ MASTER device with timer Always required first 1195 00 E720A UVBNB ADD ON device Up to 4 allowed per Master device Face Shield for MASTER device Face Shield for ADD ON device Body Home Phototherapy SolRx 1000 Series 6 foot panel with 100 waitt bulbs 10 Bulb UVB Narrowband 1000 watts 2895 00 8 Bulb UVB Narrowband 800 watts 6 Bulb UVB Narrowband 600 watts 4 Bulb UVB Narrowband 400 watts F 6 Bulb UVB Broadband 600 watts 4 Bulb UVB Broadband 400 watts Hand Foot amp Spot Phototherapy SolRx 500 Series Tabletop device with 36 wait bulbs PL L36W 01
6. ect to change without notice Note In rare cases some credit card companies have been charging the cardholder an extra transaction fee These fees are not typical completely out of Solarc s control and are payable by the purchaser Payment by wire transfer is available to avoid any such fees Contact Solarc for wire transfer information Continued 2013 Solarc Systems Inc Rev 9 2 USA Have your Healthcare Professional Medical Doctor or Nurse Practitioner complete the following Healthcare Professional Approval section OR attach a separate prescription slip where indicated below Keep a copy of your prescription for your records This is a requirement for USA shipments only per US Federal law 21CFR801 109 Prescriptions are optional for International shipments Healthcare Professional Approval To be completed by the Healthcare Professional Medical Doctor or Nurse Practitioner OR attach separate prescription slip below hereby authorize my Patient to obtain a LJUVB Narrowband UVB Broadband Ultraviolet Home Phototherapy Device as specified above The Responsible Person understands that they must read and understand the User s Manual before using the Device and that they must arrange and obtain for the Patient a skin examination performed by a Healthcare Professional at least once per year Healthcare Professional Name Address City State Phone Number Fax Number Signature Comm
7. ents lama C Dermatologist L GP L Other Please send me additional information about _ Solarc phototherapy products _ UVB Narrowband If faxing use this area to attach separate prescription slip Fully tape the top edge to prevent jamming the fax machine 2013 Solarc Systems Inc Rev 9 2 USA The following ACKNOWLEDGEMENT AND INDEMNITY AGREEMENT is an OPTIONAL agreement between the Responsible Person and the Healthcare Professional Medical Doctor or Nurse Practitioner Your Healthcare Professional may ask that you sign this agreement before issuing a prescription for an Ultraviolet Home Phototherapy Device ACKNOWLEDGEMENT AND INDEMNITY AGREEMENT TO Name of Healthcare Professional FROM Name of Responsible Person Name of Patient RE I HEREBY ACKNOWLEDGE AND CONFIRM that I have consulted with the Healthcare Professional named above to assist me with the initial selection and ongoing safe use of an Ultraviolet Home Phototherapy Device the Device I FURTHER HEREBY ACKNOWLEDGE AND CONFIRM that I have read and fully understand the content limitations and instructions contained in the Solarc Systems Inc Terms and Conditions of Sale for Ultraviolet Home Phototherapy Device the Information Document including but not limited to the following specific requirements a The Responsible Person agrees that the Device will be used only if the Responsible Person arranges and
8. lified to provide advice on ultraviolet phototherapy and qualified to perform skin examinations for skin cancer and other adverse effects The Responsible Person acknowledges that they have been advised by Solarc Systems to seek the advice of a Healthcare Professional to ensure that ultraviolet phototherapy is a suitable treatment option for the Patient s diagnosis and to evaluate the Responsible Person s ability to use the Device safely The Responsible Person agrees that the Device will be used only by the Patient The Responsible Person agrees that the Device will be used only if the Responsible Person arranges and obtains for the Patient a skin examination performed by a Healthcare Professional at least once per year The Responsible Person agrees to indemnify and hold harmless the Healthcare Professional and or Solarc Systems Inc and or any associated reseller from any action or claim if the Responsible Person fails to arrange and obtain for the Patient a skin examination performed by a Healthcare Professional at least once per year For Solarc SolRx Ultraviolet Phototherapy Lamp Unit purchases the Responsible Person agrees to read and fully understand the User s Manual supplied with the Device before the Patient s first treatment If any part of the User s Manual is not understood the Responsible Person agrees to consult with a Healthcare Professional for interpretation The Responsible Person agrees to request a replacement User s Manual
9. r the courier to call before the shipment is delivered If nobody is present at the time of delivery the courier will leave the package at the Ship To address and the delivery is considered complete Solarc provides the waybill number and courier contact information so the package can be traced and a delivery time predicted If security is an issue it is strongly recommended that the Ship To address be one that is likely to have somebody there during working hours such as a place of business Moving the package requires at least a minivan station wagon or pickup truck OR if the device is taken out of the shipping box it may fit into a smaller station wagon Typical delivery times are 3 to 9 working days for stock items 2013 Solarc Systems Inc Rev 9 2 USA CREDIT CARD INFORMATION _ VISA or _ MASTERCARD only Please print clearly Cardholder Name Total Purchase US Credit Card Expiry Date mm yy 3 digit CVD code from the back of the credit card agree to pay card issuer indicated amount pursuant to cardholder agreement Cardholder s Signature x Dated 3 Alternatively customers can call 866 813 3357 or 705 739 8279 and provide their credit card information verbally Click the box below if that is your preference L will call Solarc and provide my credit card information verbally Solarc may also request the cardholder s address Pricing valid from June 01 2013 and subj
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