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| HCA Order Form | 
| Division | North Florida Division | ||
| Site/Hospital | Lake Nona Hospital | ||
| Billing | Delivery | ||
| Name | dan.fran@hcahealthcare.com | Name | Dan Franceschini | 
| George.Greene1@healthtrustpg.com | dan.fran@hcahealthcare.com | ||
| Address Line 1 | Clinical Education Financial Reporting | Address Line 1 | 6400 Sanger Rd | 
| Address Line 2 | Clinical Education Financial Reporting | Address Line 2 | |
| Address Line 3 | Suite 1100 | Address Line 3 | |
| City | Nashville | City | Orlando | 
| State | TN | State | Florida | 
| ZIP | 37203 | ZIP | 32827 | 
| Items to Order | |||
| Code | Description | Quantity | Total ($) | 
| S17011 | Brayden Baby/Infant Artificial Lung Air Guide | 25 | $41.50 | 
| Sub-Total | $41.50 | ||
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