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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 | 
| George.Greene1@healthtrustpg.com | 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 | ||
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