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HCA Order Form
Division North Texas Division
Site/Hospital NTXD HHCCA
Billing Delivery
Name marlo.cooper@medicalcityhealth.com Name Marlo Cooper
Email George.Greene1@healthtrustpg.com Email marlo.cooper@medicalcityhealth.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 3201 Dallas Parkway
Address Line 2 Clinical Education Financial Reporting Address Line 2 Suite 900
Address Line 3 Suite 1100 Address Line 3
City Nashville City Frisco
State TX State TX
ZIP 37203 ZIP 75034
Items to Order
Code Description Quantity Total ($)
C99008 Brayden Premium Urethane Adult Lung Kit (Pack of 6) 2 $176.40
2 $0.00
S17011 Brayden Baby/Infant Artificial Lung Air Guide 12 $18.96
S17008 Brayden Baby/Infant Spring 2 $30.46
S17013 Brayden Baby/Infant Replacement Airway Tube (single) 12 $34.68
S16402 Brayden Pro Adult Body Skin Magnet 8 $31.52
C17006 Brayden Baby/Infant Double Filter (Pack of 5) 1 $28.35
A99003 Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug 8 $117.20
$0.00
  Sub-Total $437.57