EVERSIGHT SERVICES
SURGEON FORMS
INVOICE INFORMATION SHEET
Name of hospital/surgery center for billing:______________________________________________
Billing address:________________________________________________________________________
Shipping address (if different):__________________________________________________________
City, State, Zip:________________________________________________________________________
Telephone:______________________________________________
Fax:_____________________________________________________
Facility hours:___________________________________________
Delivery instructions:___________________________________________________________________
Does this facility require a Purchase Order Number for payment of tissue received?
No
Yes - please check all applicable boxes below:
❐ ❐ Standing PO Number:__________________________ Expires:__________
❐ ❐ Individual PO Number:_________________________
❐ ❐ PO Number required prior to receipt of tissue
Hospital/surgery center accounts payable contact:________________________________________
Telephone:____________________ Email:________________________________________________
Hospital/surgery center purchasing dept. contact:________________________________________
Telephone:____________________ Email:________________________________________________
Hospital/surgery center operating room contact:_________________________________________
Telephone:____________________ Email:________________________________________________
Questions regarding billing? Please contact our Finance Department at (734) 887-2309.
Questions regarding shipping? Please contact our Tissue Placement Department at (866) 900-8119.
*Revised January 30, 2017
Tissue Placement: (866) 900-8119 • Fax (734) 780-2730 • [email protected]