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HCA Order Form
Division Gulf Coast Division
Site/Hospital HCA Houston Healthcare Conroe
Billing Delivery
Name sarah.prial@hcahealthcare.com Name Karen king
Email George.Greene1@healthtrustpg.com Email karen.king1@hcahealthcare.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 504 Medical Center Blvd
Address Line 2 Clinical Education Financial Reporting Address Line 2
Address Line 3 Suite 1100 Address Line 3
City Nashville City Conroe
State TN State TX
ZIP 37203 ZIP 77304
Items to Order
Code Description Quantity Total ($)
C99007 Brayden Adult Lung Kit Version A04 (Pack of 24) 2 $99.22
C17001 Brayden Baby/Infant Replacement Lung (single) 2 $19.84
  Sub-Total $119.06