Purchase Order Orthodontist in United States Chicago –Free Word Template Download with AI
Lakeview Orthodontic Associates, LLC
2155 N. Lake Shore Drive, Suite 400, Chicago, Illinois 60614, United States
Phone: (312) 555-0187 | Email: [email protected]
Tax ID (EIN): 36-4829175 | Illinois Business License: 123-456789
Line Items – Orthodontic Equipment and Supplies| Item # | Description | SKU | Qty | Unit Price (USD) | Line Total (USD) |
|---|---|---|---|---|---|
| 1 | Self-Ligating Orthodontic Brackets – Ceramic, 144-piece set (upper and lower arches) | MO-CL-144C | 25 | $389.00 | $9,725.00 |
| 2 | NiTi Archwires – 0.014" to 0.021" x 0.025" progressive set, 120-pack | MO-NI-120P | 40 | $127.50 | $5,100.00 |
| 3 | Orthodontic Elastics – Assorted colors and sizes, 5000-piece bulk box | MO-EL-5000B | 60 | $42.00 | $2,520.00 |
| 4 | Digital Intraoral Scanner – 3Shape TRIOS 5 (replacement unit for Chicago clinic) | MO-DS-TR5 | 1 | $18,500.00 | $18,500.00 |
| 5 | Orthodontic Bonding Agent Kit – Etch, primer, and adhesive, 24-bottle case | MO-BK-24C | 15 | $96.75 | $1,451.25 |
| 6 | Clear Aligner Retainers – Custom-molded, 30-pair monthly supply | MO-CA-30P | 12 | $210.00 | $2,520.00 |
| 7 | Orthodontic Forceps and Pliers – 12-piece stainless steel set | MO-FP-12S | 8 | $312.00 | $2,496.00 |
| 8 | Patient Education Materials – Brackets, aligners, and aftercare brochures (500 sets) | MO-PE-500S | 10 | $85.00 | $850.00 |
| 9 | CBCT Imaging Software License – Annual renewal for Chicago practice | MO-SW-CBCT | 1 | $4,200.00 | $4,200.00 |
| 10 | Orthodontic Wax and Emergency Repair Kits – 200-unit case | MO-WX-200U | 20 | $38.50 | $770.00 |
Subtotal: $48,132.25
Illinois State Sales Tax (8.75%): $4,211.57
Chicago Municipal Tax (2.5%): $1,203.31
Shipping and Handling (Freight to United States Chicago): $685.00
Grand Total Due: $54,232.13 USD
Terms and Conditions- Payment Terms: Net 30 days from the date of this Purchase Order. Payment shall be made via ACH transfer to the vendor account on file. Late payments shall accrue interest at 1.5% per month as permitted under Illinois commercial code.
- Delivery: All items listed in this Purchase Order must be delivered to the Lakeview Orthodontic Associates facility at 2155 N. Lake Shore Drive, Suite 400, Chicago, Illinois 60614, United States. Delivery must be completed no later than July 15, 2025. The vendor is responsible for all freight charges and insurance during transit to the United States Chicago location.
- Quality Assurance: All orthodontic products must meet or exceed the standards set by the American Association of Orthodontists (AAO) and comply with FDA regulations. The Orthodontist in charge, Dr. Sarah Mitchell, DDS, MS, will inspect all deliveries upon arrival. Any defective or non-conforming items must be replaced within five (5) business days at no additional cost to the buyer.
- Warranty: The digital intraoral scanner (Item #4) carries a two-year manufacturer's warranty. All other consumable items are warranted to be free from manufacturing defects for a period of ninety (90) days from the date of delivery.
- Cancellation and Modification: This Purchase Order may be modified or cancelled in writing by either party with a minimum of ten (10) business days' notice. Cancellation after the vendor has commenced manufacturing or procurement of custom items may incur a 15% restocking fee.
- Governing Law: This Purchase Order shall be governed by and construed in accordance with the laws of the State of Illinois, United States. Any disputes arising from this agreement shall be resolved in the Cook County Circuit Court, Chicago, Illinois.
- Compliance: The vendor certifies that all orthodontic materials and equipment supplied under this Purchase Order are manufactured in compliance with applicable United States federal and state regulations, including but not limited to FDA 21 CFR and Illinois Department of Public Health guidelines for dental and orthodontic practices.
- Confidentiality: Both parties agree to maintain the confidentiality of all pricing, patient-related information, and proprietary business data exchanged in connection with this Purchase Order. This obligation survives the termination of this agreement for a period of three (3) years.
For Lakeview Orthodontic Associates, LLC (Buyer)
Dr. Sarah Mitchell, DDS, MS – Lead Orthodontist
Signature: ______________________________Date: ______________________________
For Midwest Orthodontic Supply Co. (Vendor)
Daniel Reeves – Sales Director
Signature: ______________________________Date: ______________________________ ⬇️ Download as DOCX Edit online as DOCX
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