85 S Bragg St Ste 503, Alexandria, VA 22312
Office: 703.858.7778 | E-Fax: 703.722.3883
Website: www.proxdose.com/monitoring
Dosimetry Order Form
Dosimetry Order Form
Company:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Company"
as=${html``}
/>
Phone:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Phone"
as=${html``}
/>
Contact Name:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Contact_Name_"
as=${html``}
/>
Email:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Email_"
as=${html``}
/>
Address:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Address-"
as=${html``}
/>
City:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="City:"
as=${html``}
/>
State:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="State"
as=${html``}
/>
Zip:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Zip:"
as=${html``}
/>
Fax:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Fax_"
as=${html``}
/>
Payment Information*
Card Number:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Card_Number__"
as=${html``}
/>
Cardholder Name:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Cardholder_Name_"
as=${html``}
/>
Expiration Date:
<${props.Flatpickr}
name="Expiration_Date__"
className="mf-input mf-date-input mf-left-parent "
placeholder="${ parent.decodeEntities(``) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('Expiration_Date__')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['Expiration_Date__'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":false},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Expiration_Date__"
as=${html``}
/>
Security Code:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Security_Code_"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
class="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-4b6e6bc">
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-checkbox__"
as=${html``}
/>
Ship To
parent.handleCheckbox(el, 'onLoad')}
class="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-8e7bee0">
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-checkbox"
as=${html``}
/>
Company:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Company_-"
as=${html``}
/>
Phone:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Phone__"
as=${html``}
/>
Fax:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Fax__"
as=${html``}
/>
Address:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Address_"
as=${html``}
/>
City:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="City_"
as=${html``}
/>
State:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="State_"
as=${html``}
/>
Zip:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Zip_"
as=${html``}
/>
Billing Address
Company:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Company__"
as=${html``}
/>
Phone:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Phone__"
as=${html``}
/>
Fax:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Fax__"
as=${html``}
/>
Address:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Address__"
as=${html``}
/>
City:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="City__"
as=${html``}
/>
State:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="State__"
as=${html``}
/>
Zip:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Zip__"
as=${html``}
/>
Requested Start Date
<${props.Flatpickr}
name="Requested_Start_Date"
className="mf-input mf-date-input mf-left-parent "
placeholder="${ parent.decodeEntities(``) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('Requested_Start_Date')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['Requested_Start_Date'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":false},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Requested_Start_Date"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
class="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-3bc0bd0">
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-checkboxff"
as=${html``}
/>
Requested End Date
<${props.Flatpickr}
name="Requested_End_Date"
className="mf-input mf-date-input mf-left-parent "
placeholder="${ parent.decodeEntities(``) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('Requested_End_Date')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['Requested_End_Date'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":false},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Requested_End_Date"
as=${html``}
/>
Exchange Frequency
parent.handleCheckbox(el, 'onLoad')}
class="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-a5b7204">
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-checkbox"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Authorized_First_Name__"
as=${html``}
/>
Authorized by (Print Full Name)
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Signature"
as=${html``}
/>
Signature
Agree to terms and conditions (initials):
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="initials"
as=${html``}
/>
Service Terms and Conditions:
Control Dosimeters – One included at half rate; extras at standard price.
Billing – Subscriptions billed in advance.
Shipping – Free U.S. shipping; Easy Return label $9.95;
rush/extra shipments billed.
Renewal – Auto-renews yearly unless cancelled 30 days prior.
Damaged Badges – $35 replacement fee.
Account Changes – Wearer List changes due 30 days prior to
issue period to sales@proxdose.com or 703.858.7778; late
changes incur rush fee.
Cancellation – Written cancellation required; prorated
refund if received 30 days before next issue period.