Purchase Order Optometrist in United States Chicago –Free Word Template Download with AI
Purchase Order Details
PO Number: PO-2025-04871
Date Issued: June 12, 2025
Required Delivery Date: July 15, 2025
Payment Terms: Net 30 Days
Currency: USD (United States Dollar)
Buyer (Optometrist Practice)
Lakeview Optometry Associates, LLC
2145 N. Lake Shore Drive, Suite 300
Chicago, Illinois 60614
United States
Tel: (312) 555-0187
Email: [email protected]
IL License No. 259.001234
Vendor / Supplier
OptiSource Medical Supply Co.
8800 W. Cermak Road, Building C
Chicago, Illinois 60655
United States
Tel: (773) 555-0442
Email: [email protected]
Tax ID: 36-2847190
The following Purchase Order covers the procurement of diagnostic equipment, patient care supplies, and office materials required to maintain and expand the optometrist practice operations at our United States Chicago location. All items must comply with FDA regulations and Illinois state medical device standards.
| # | Item Description | SKU / Part No. | Qty | Unit Price (USD) | Extended Price (USD) | Delivery Notes |
|---|---|---|---|---|---|---|
| 1 | Topcon AutoRef RA-120 Autorefraction / Keratometry Unit — for comprehensive optometrist patient examinations | TC-AR-120-2025 | 1 | $18,450.00 | $18,450.00 | White-glove delivery; installation required |
| 2 | Heine Omega 200 Direct Ophthalmoscope (set of 4) — standard optometrist diagnostic tool | HN-OM200-4PK | 4 | $312.00 | $1,248.00 | Standard shipping |
| 3 | Zeiss I-PRO 100 Digital Fundus Camera — retinal imaging for optometrist practice | ZS-IP100-2025 | 1 | $24,900.00 | $24,900.00 | White-glove delivery; calibration included |
| 4 | Disposable Trial Lens Frames (assorted powers, -10.00 to +10.00) — 200-pack | DL-TLF-200 | 5 | $189.00 | $945.00 | Standard shipping |
| 5 | Non-Contact Tonometer (NCT) — intraocular pressure measurement for optometrist use | NC-TON-500 | 2 | $2,150.00 | $4,300.00 | Standard shipping; air supply adapter included |
| 6 | Phoropter (auto-centering, 6-position) — primary optometrist refraction instrument | PH-AC6-2025 | 2 | $6,780.00 | $13,560.00 | White-glove delivery; mounting hardware included |
| 7 | Patient Examination Chairs (hydraulic, adjustable, with armrests) — optometrist exam room | EX-CH-700 | 4 | $1,240.00 | $4,960.00 | Freight; assembly on site |
| 8 | Disposable Specimen Slides & Covers (10,000 units) — for corneal abrasion assessment | DS-SC-10K | 10 | $42.00 | $420.00 | Standard shipping |
| 9 | LED Slit Lamp Biomicroscope (with 10x/16x/25x magnification) — optometrist anterior segment exam | SL-LED-25X | 2 | $8,950.00 | $17,900.00 | White-glove delivery; technician setup |
| 10 | Office Supply Bundle: patient intake forms, consent documents, Illinois medical record templates (5,000 sets) | OS-PF-5K-IL | 1 | $1,150.00 | $1,150.00 | Standard shipping |
| Subtotal | $88,833.00 |
| Illinois State Sales Tax (8.75%) | $7,772.89 |
| Freight & White-Glove Delivery | $2,340.00 |
| Installation & Calibration Service | $3,200.00 |
| Grand Total (USD) | $102,145.89 |
Terms and Conditions
- This Purchase Order is issued by Lakeview Optometry Associates, LLC, a licensed optometrist practice operating in the United States Chicago metropolitan area, and constitutes a binding agreement upon acceptance by the vendor.
- All equipment and supplies listed in this Purchase Order must be new, unused, and in original manufacturer packaging. Any item found to be defective or non-conforming upon delivery shall be returned at the vendor's expense within fourteen (14) calendar days.
- Delivery shall be made to the optometrist practice address listed above in Chicago, Illinois, United States. The vendor is responsible for all transportation, insurance, and risk of loss until goods are received and signed for by authorized personnel at the receiving location.
- Payment shall be remitted within thirty (30) days of the invoice date via ACH transfer to the account designated by the vendor. Late payments shall accrue interest at a rate of 1.5% per month, in accordance with Illinois commercial code provisions.
- All medical devices and optical instruments must carry valid FDA 510(k) clearance or exemption documentation. The vendor shall provide certificates of compliance and warranty documentation (minimum two-year manufacturer warranty) with each shipment.
- The vendor agrees to provide on-site installation, calibration, and operator training for all capital equipment items (items #1, #3, #6, and #9) at no additional charge beyond the installation fee stated in this Purchase Order.
- This Purchase Order is governed by the laws of the State of Illinois and the United States. Any disputes arising from this agreement shall be resolved through binding arbitration in Cook County, Chicago, Illinois, in accordance with the rules of the American Arbitration Association.
- The vendor acknowledges that all patient data and practice information shared in connection with this Purchase Order shall be treated as confidential and protected under HIPAA (Health Insurance Portability and Accountability Act) regulations as applicable to the United States.
- Modifications to this Purchase Order must be made in writing and signed by both parties. No verbal agreements or side letters shall alter the terms herein.
- This Purchase Order is valid for acceptance until June 26, 2025. Failure to confirm acceptance by this date shall render this document null and void.
Authorized Buyer — Optometrist Practice
Name: Dr. Sarah M. Whitfield, O.D.
Title: Managing Partner, Lakeview Optometry Associates, LLC
Signature: ___________________________
Date: ___________________________
Vendor Acceptance
Name: ___________________________
Title: ___________________________
Signature: ___________________________
Date: ___________________________
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