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HCA Order Form
Division Capital Division
Site/Hospital Chippenham
Billing Delivery
Name Tracy.Harrell@hcahealthcare.com Name Michelle Ford
Email George.Greene1@healthtrustpg.com Email Michelle.Ford2@hcahealthcare.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 7101 Jahnke Rd
Address Line 2 Clinical Education Financial Reporting Address Line 2
Address Line 3 Suite 1100 Address Line 3
City Nashville City Richmond
State TN State VA
ZIP 37203 ZIP 23225
Items to Order
Code Description Quantity Total ($)
[980] Brayden Baby/Infant Replacement Lung (single) 3 $27.00
[980] Brayden Premium Urethane Adult Lung Kit (Pack of 6) 1 $84.00
[980] Brayden Baby/Infant Replacement Airway Tube (single) 3 $8.25
[980] Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug 4 $55.80
[980] $0.00
  Sub-Total $175.05