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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 | Clyde.Owen@MedicalCityHealth.com | ||
| Address Line 1 | Clinical Education Financial Reporting | Address Line 1 | 3401 Dallas Tollway | 
| 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 | TN | State | TX | 
| ZIP | 37203 | ZIP | 75201 | 
| Items to Order | |||
| Code | Description | Quantity | Total ($) | 
| A99002 | Brayden Adult Compression Spring Addon | 5 | $113.50 | 
| S13106 | Brayden Adult Face/Mouth Connector | 5 | $12.60 | 
| C17003 | Brayden Baby/Infant Body Skin | 5 | $288.75 | 
| S17011 | Brayden Baby/Infant Artificial Lung Air Guide | 15 | $23.70 | 
| C17001 | Brayden Baby/Infant Replacement Lung (single) | 20 | $189.00 | 
| C99008 | Brayden Premium Urethane Adult Lung Kit (Pack of 6) | 7 | $617.40 | 
| $0.00 | |||
| A99003 | Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug | 12 | $175.80 | 
| S16402 | Brayden Pro Adult Body Skin Magnet | 12 | $47.28 | 
| S17013 | Brayden Baby/Infant Replacement Airway Tube (single) | 14 | $40.46 | 
| $0.00 | |||
| Sub-Total | $1,508.49 | ||
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