TYPE AND FREQUENCY OPTION: See pricing options *
Offer Code (if any):
Preferred Start Date (if any):
Comments:
Billing Information

* - Required Field
Company Name: *
Contact Name: *
 
Address: *
Address (line 2)
City: *
State: *
Zip Code: *
 
Phone: *
Fax:
Email: (If you don’t provide your email, you will not receive an order confirmation.)
Shipping Information Same as Billing?
Reporting Information Same as Billing?
Badge Assignment Information

Select the box for Whole Body to order that badge for the individual. If that person needs rings, select the box for Left and/or Right hand and indicate the ring size. Adding a name to the field will allow us to maintain the name with the record. It is the most secure way to ensure proper record retention. (for example, Joe Smith, Room 1, Tech 1, Visitor, Spare, Spare 2.). Each dosimeter is individually counted to determine the final cost.

Badge Assignment Information is not needed for Instadose orders. However, Please fill out Name, Gender and Date of birth for Instadose+ orders.
Name
(First Last)		Gender
(M/F)		Date of BirthWhole Body/Area?Left Hand?Right Hand?Ring Size
(S/M/L/XL)
Add wearers here:  
Shipping Options
*Express shipping orders must be made before noon Eastern time to be delivered next day.
How Did you Find Us: if Other(please let us know in the comments) : *
Payment Options
Pay : Now       Later (This order will not be processed until payment or other arrangements (such as P.O.) have been made with CHP. Paying now is the most secure method.)
SUBTOTAL:
DISCOUNT:
Tax:
TOTAL:
By clicking the submit button, you are agreeing to our terms and conditions for Instadose/Instadose+ or for all other products, terms and conditions**, which includes an $18/ea fee for damaged or lost or unreturned dosimeters (they are deemed late if they are sent in past 91+ days after the end of the wear period, including the control, and will still incur an $18/ea fee.)