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Purchase Order Doctor General Practitioner in United States Chicago –Free Word Template Download with AI

Medical & Clinical Supply Procurement Document

Issued for the Practice of a Doctor General Practitioner in United States Chicago

Purchase Order No.: PO-CHI-2025-04872
Date of Issue: June 12, 2025
Required Delivery Date: July 1, 2025
Payment Terms: Net 30 Days
Currency: USD (United States Dollars)
Incoterms: DDP – United States Chicago
1. BUYER INFORMATION (RECEIVING PARTY) Dr. Margaret A. Whitfield, MD – Doctor General Practitioner
Lakeview Family Medicine & Primary Care Associates
2145 North Lake Shore Drive, Suite 380
United States Chicago, Illinois 60614
Telephone: (312) 555-0198
Email: [email protected]
NPI Number: 1497823651
Illinois Medical License: 231.004872
2. VENDOR / SUPPLIER INFORMATION MedSource Distribution Partners, LLC
8800 West Cermak Road, Building C
United States Chicago, Illinois 60655
Telephone: (773) 555-4421
Email: [email protected]
Tax ID (EIN): 36-2847195
Illinois Business License: IL-2019-77834
3. LINE ITEMS – MEDICAL SUPPLIES AND EQUIPMENT
Item # Description SKU / Catalog Ref. Qty Unit Price (USD) Line Total (USD)
001 Disposable Nitrile Examination Gloves, Medium, Box of 100 (FDA-cleared for Doctor General Practitioner use) NSN-GLV-2201 200 $12.50 $2,500.00
002 Electronic Blood Pressure Monitor, Cuff, Wall-Mount (Clinic Grade for United States Chicago primary care offices) BPX-WM-4410 4 $385.00 $1,540.00
003 Stethoscope, Dual Head, Lightweight (Standard issue for Doctor General Practitioner consultations) STH-DH-0092 6 $95.00 $570.00
004 Thermometer, Infrared Forehead, Clinical Grade (For patient intake in United States Chicago clinics) THM-IR-3305 8 $62.00 $496.00
005 Autoclave Sterilizer, 25L Capacity, CE & FDA Compliant (For Doctor General Practitioner instrument sterilization) ACL-25L-7781 1 $2,850.00 $2,850.00
006 Exam Table Paper Rolls, 18-inch, 1000 sheets per roll (Standard for United States Chicago medical offices) EXM-TPR-1800 50 $8.75 $437.50
007 Isopropyl Alcohol 70%, 1 Gallon Jug (Disinfectant for Doctor General Practitioner examination rooms) ALC-70-1G 30 $14.25 $427.50
008 Patient Intake Forms & HIPAA Consent Packets, 500 sets (Required for United States Chicago healthcare compliance) FRM-HIP-5000 10 $45.00 $450.00
009 Portable ECG / EKG Machine, 12-Lead, with Software (Diagnostic tool for Doctor General Practitioner cardiology screening) ECG-12L-6620 2 $1,240.00 $2,480.00
010 Medical Waste Sharps Containers, 2L, Puncture-Resistant (OSHA-compliant for United States Chicago facilities) SHR-2L-8834 40 $6.50 $260.00
Subtotal: $12,011.00
Illinois State Sales Tax (8.75%): $1,050.96
Shipping & Handling (United States Chicago Metro): $185.00
TOTAL AMOUNT DUE (USD): $13,246.96
4. TERMS AND CONDITIONS
  1. This Purchase Order is issued by Dr. Margaret A. Whitfield, a licensed Doctor General Practitioner operating in United States Chicago, Illinois, and constitutes a binding procurement request for the medical supplies and equipment listed herein.
  2. All items must comply with the Food and Drug Administration (FDA) regulations, the Occupational Safety and Health Administration (OSHA) standards, and the Illinois Department of Public Health guidelines applicable to primary care practices in United States Chicago.
  3. Delivery shall be made to the receiving address listed in Section 1. The vendor is responsible for all transportation costs within the United States Chicago metropolitan area. Late delivery beyond the Required Delivery Date of July 1, 2025, will incur a penalty of 1.5% of the total Purchase Order value per business day.
  4. Payment shall be remitted via ACH transfer to the vendor's designated bank account within thirty (30) calendar days of receipt of a valid invoice and confirmed delivery of all line items. The Doctor General Practitioner's office reserves the right to withhold payment for any items found defective, damaged, or non-conforming to the specifications stated in this Purchase Order.
  5. All medical devices and equipment must arrive with valid FDA 510(k) clearance documentation, manufacturer certificates of analysis, and applicable warranty documentation. The Doctor General Practitioner practice in United States Chicago requires a minimum two-year manufacturer warranty on all electronic and mechanical equipment.
  6. The vendor acknowledges that all patient-related materials (including HIPAA consent packets) must be handled in strict accordance with the Health Insurance Portability and Accountability Act (HIPAA) and the Illinois Personal Information Protection Act.
  7. This Purchase Order is subject to the laws of the State of Illinois and the federal laws of the United States. Any disputes arising from this Purchase Order shall be resolved through binding arbitration in Cook County, United States Chicago, Illinois.
  8. The vendor warrants that all goods are new, unused, and free from defects in materials and workmanship. The Doctor General Practitioner reserves the right to reject any shipment that does not meet the quality standards expected of a primary care medical practice in United States Chicago.
  9. Any modifications, cancellations, or amendments to this Purchase Order must be made in writing and signed by both the Doctor General Practitioner (or her authorized designee) and the vendor's authorized representative.
5. DELIVERY AND RECEIVING INSTRUCTIONS

Delivery shall be made between the hours of 8:00 AM and 4:00 PM, Monday through Friday, to the loading dock at 2145 North Lake Shore Drive, United States Chicago, IL 60614. The receiving contact is Mr. David Chen, Office Manager, reachable at (312) 555-0199. All deliveries must be scheduled in advance with a minimum of 48 hours' notice. The vendor must provide a Bill of Lading and packing list with each shipment. The Doctor General Practitioner's staff will inspect all items upon arrival and sign the delivery receipt only after confirming quantity and condition.

6. AUTHORIZATION AND SIGNATURES

Authorized by (Buyer):

Dr. Margaret A. Whitfield, MD
Doctor General Practitioner
Lakeview Family Medicine & Primary Care Associates
United States Chicago, IL 60614
Date: ______________________

Accepted by (Vendor):

Jonathan R. Park, Sales Director
MedSource Distribution Partners, LLC
United States Chicago, IL 60655
Date: ______________________

This Purchase Order (PO-CHI-2025-04872) was prepared for the practice of a Doctor General Practitioner located in United States Chicago, Illinois. This document is confidential and intended solely for the named parties. Unauthorized reproduction or distribution is prohibited. For questions regarding this Purchase Order, contact the procurement office at Lakeview Family Medicine & Primary Care Associates, United States Chicago, IL 60614.

Document Version 1.0 | Generated: June 12, 2025 | Page 1 of 1

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