Purchase Order Dentist in United States Chicago –Free Word Template Download with AI
Lakeview Dental Practice, P.C.
2145 N. Lakeview Avenue, Suite 300, Chicago, Illinois 60614, United States
Phone: (312) 555-0187 | Fax: (312) 555-0188 | Email: [email protected]
Illinois Dental License No. 17-048291 | EIN: 36-2847195
PO No. LDC-2025-00472Buyer (Dentist Practice)
Lakeview Dental Practice, P.C.
Attn: Dr. Margaret Sullivan, DDS, MS
Principal Dentist & Owner
2145 N. Lakeview Avenue, Suite 300
Chicago, Illinois 60614, United States
Vendor / Supplier
Midwest Dental Supply Co., Inc.
Attn: Accounts Receivable Department
4820 Industrial Parkway, Building C
Chicago, Illinois 60639, United States
Order Information
PO Date: June 12, 2025
Required Delivery Date: June 26, 2025
Payment Terms: Net 30 Days
Shipping Method: Ground Freight (FOB Destination)
Delivery Address: Chicago, United States
| Item # | Description | SKU / Catalog No. | Qty | Unit Price (USD) | Extended Price (USD) |
|---|---|---|---|---|---|
| 1 | Digital Dental X-Ray Sensor (Intraoral, 2048x2048 resolution) – for use in the Dentist's operatory at our Chicago, United States location | DXS-2048-PRO | 2 | $3,450.00 | $6,900.00 |
| 2 | Composite Resin Filling Material, Universal Shade Kit (24 shades), 4g syringes – bulk order for the Dentist's restorative procedures | CRU-24-4G | 12 | $187.50 | $2,250.00 |
| 3 | Autoclave Sterilizer, 24L Capacity, Class B – replacement unit for the Dentist's sterilization room in Chicago, United States | ACL-24B-STD | 1 | $4,890.00 | $4,890.00 |
| 4 | Nitrile Examination Gloves, Powder-Free, Size M (Box of 100) – monthly supply for the Dentist and four hygienists | NGM-100-STD | 60 | $14.25 | $855.00 |
| 5 | Dental Handpiece, High-Speed Turbine (40,000 RPM) with Water Spray – for the Dentist's operative dentistry | DHT-40K-WS | 3 | $620.00 | $1,860.00 |
| 6 | Prophylaxis Paste, Fluoride-Containing (0.1% NaF), 120g tubes – for the Dentist's preventive care appointments | PPF-120-FL | 48 | $8.75 | $420.00 |
| 7 | LED Curing Light, 1000 mW/cm², with 3 Tips – for the Dentist's composite bonding and orthodontic procedures | LCL-1000-3T | 2 | $415.00 | $830.00 |
| 8 | Patient Dental Chair, Hydraulic, with Headrest and Armrests – new installation for the Dentist's expanded operatory in Chicago, United States | DCP-HYD-STD | 1 | $7,200.00 | $7,200.00 |
| 9 | Surgical Suture Kit, Absorbable, 3-0 through 5-0, 100-pack – for the Dentist's oral surgery cases | SSK-ABS-3050 | 10 | $96.00 | $960.00 |
| 10 | Dental Impression Material, Polyvinyl Siloxane (PVS), Medium Viscosity, 300ml cartridges – for the Dentist's prosthodontic work | PVSM-300-C | 24 | $32.50 | $780.00 |
| Subtotal | $27,945.00 |
| Illinois State Sales Tax (8.75%) | $2,445.19 |
| Freight & Delivery (Chicago, United States) | $385.00 |
| TOTAL AMOUNT DUE (USD) | $30,775.19 |
This Purchase Order is issued by Lakeview Dental Practice, P.C., a licensed dental practice operating in Chicago, Illinois, United States, and is governed by the laws of the State of Illinois. The Dentist, Dr. Margaret Sullivan, DDS, MS, is the authorized purchasing agent for this Purchase Order and all related transactions.
All items listed in this Purchase Order must be delivered to the Dentist's practice facility located at 2145 N. Lakeview Avenue, Suite 300, Chicago, Illinois 60614, United States, no later than the required delivery date specified above. Late deliveries will be subject to a penalty of 2% of the total Purchase Order value per business day, up to a maximum of 10%.
The vendor acknowledges that all dental equipment and supplies listed herein must comply with the Food and Drug Administration (FDA) regulations applicable in the United States, as well as the Illinois Department of Public Health standards for dental practice in Chicago. All sterilization equipment must bear the appropriate UL listing and meet the American Dental Association (ADA) specifications.
Payment for this Purchase Order shall be made via ACH transfer to the vendor's designated account within thirty (30) calendar days of the date of receipt of a valid invoice. The Dentist reserves the right to withhold payment for any items that do not conform to the specifications outlined in this Purchase Order or that arrive damaged during transit to the Chicago, United States facility.
All equipment with a unit price exceeding $1,000.00 shall include a minimum two-year manufacturer's warranty. The Dentist's practice in Chicago, United States, shall be the designated service location for any warranty repairs or replacements. The vendor shall provide a written warranty certificate with each applicable item.
This Purchase Order does not constitute a binding contract until countersigned by an authorized representative of the vendor. The Dentist reserves the right to modify, cancel, or reject any portion of this Purchase Order in writing prior to shipment. All modifications must be approved in writing by Dr. Sullivan, the principal Dentist of record.
NOTE: This Purchase Order is part of the annual equipment renewal cycle for Lakeview Dental Practice, P.C. The Dentist has requested priority handling for Items #1, #3, and #8 due to the expansion of the practice's operatory capacity in the Lakeview neighborhood of Chicago, United States. Please confirm availability and estimated shipping timeline within two (2) business days of receipt of this Purchase Order.Prepared by (Dentist / Buyer):
Dr. Margaret Sullivan, DDS, MS
Principal Dentist, Lakeview Dental Practice, P.C.
Chicago, Illinois, United States
Date: _________________________
Signature: _________________________
Accepted by (Vendor):
Midwest Dental Supply Co., Inc.
Authorized Representative: _________________________
Title: _________________________
Date: _________________________
Signature: _________________________
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