Additional Cylinder Order Form Cylinder Order Form Additional Cylinder Order Form Step 1 of 13 7% Customer Facility Name First Name of Person Placing the OrderPhone Number of Ordering PersonPhone Number of Receiving PersonAddress Street Address For which type of facility do you need cylinders? For Aesthetic Surgical Center Oral Dental, Animal Centers. For Hospital, Nursing, and Rehabilitation. For Fire Department, & EMS Rescue. Private doctors & clinics. DME Medical Suppliers. For Neurologist, Imaging, Cryo-Stencils Cryobank, Cryo-preservation, and Dialysis Centers. For Night Clubs, Bars, Outdoor concert, and Restaurant. For Dermatologist. For industrial welding, electronics, aviation, automotive, applications . For Aesthetic Surgical Center Oral Dental, Animal Centers. Compressed Oxygen Oxygen E small 2’ tall (Silver & Green) Additional Cylinders(Required) Oxygen H large 5’4” tall (All Green) Additional Cylinders(Required) Oxygen T large 6’ tall (All Green) Additional Cylinders(Required) Oxygen E grab-&-Go built-in regulator (2’ tall, Silver & Green) Additional Cylinders(Required) NF Medical Grade Nitrous-Oxide Nitrous-oxide E small 2’ tall (Silver & Blue) Additional Cylinders(Required) Nitrous-oxide H small 5’4” tall (All Blue) Additional Cylinders(Required) NF Medical Grade Carbon-Oxide CO2 Carbon Dioxide NF Medical Grade 7 LBS. (2’ tall, Silver & Grey) Additional Cylinders(Required) CO2 Carbon Dioxide NF Medical Grade 15 LBS. (2 1/2’ tall, Silver & Grey) Additional Cylinders(Required) Compress Medical Air USP Grade Medical Air USP Grade E Small 2’ tall (Silver & Yellow) Additional Cylinders(Required) Medical Air USP Grade H Small 5’4” tall (All Yellow) Additional Cylinders(Required) Compress Helium Balloon Grade Helium Compress Balloon Grade H Large 5’4” tall (All Yellow) Additional Cylinders(Required) JAG-Plasma Surgical Compress Helium Industrial Grade Helium Compress Industrial Grade 40 cf. (Small 19” tall, Brown) Additional Cylinders(Required)Liquid Oxygen Liquid O2 Oxygen Refill “Medical Grade” Additional Cylinders(Required) 230 large drum (4’ tall) & 3’ in diameter Additional Cylinders(Required) Material: Stainless steel chrome Additional Cylinders(Required)ACKNOWLEDGEMENT (Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. For Hospital, Nursing, and Rehabilitation Compressed Oxygen Oxygen E small 2’ tall (Silver & Green) Additional Cylinders(Required) Oxygen H large 5’4” tall (All Green) Additional Cylinders(Required) Oxygen T large 6’ tall (All Green) Additional Cylinders(Required) Oxygen E grab-&-Go built-in regulator (2’ tall, Silver & Green) Additional Cylinders(Required) NF Medical Grade Carbon-Oxide Size E – CO2 Carbon Dioxide NF Medical Grade 7 LBS. (2’ tall, Silver & Grey) Additional Cylinders(Required) Size F – CO2 Carbon Dioxide NF Medical Grade 15 LBS. (2 1/2’ tall, Silver & Grey) Additional Cylinders(Required) CO2 Carbon Dioxide NF Medical Grade 50 LBS. (5’4” tall, Silver & Grey) Additional Cylinders(Required) Medical Grade Nitrous-Oxide Nitrous-oxide E small 2’ tall (Silver & Blue) Additional Cylinders(Required) Nitrous-oxide H small 5’4” tall (All Blue) Additional Cylinders(Required) Compress Medical Air USP Grade Medical Air USP Grade E Small 2’ tall (Silver & Yellow) Additional Cylinders(Required) Medical Air USP Grade H Small 5’4” tall (All Yellow) Additional Cylinders(Required)Liquid Oxygen Liquid Nitrogen Refill “Medical Grade” Additional Cylinders(Required) Liquid O2 oxygen Refill “Medical Grade” Additional Cylinders(Required) 230 large drum (4’ tall) & 3’ in diameter Additional Cylinders(Required) Material: Stainless steel chrome Additional Cylinders(Required)ACKNOWLEDGEMENT(Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. For Fire Department, & EMS Rescue. Compressed Oxygen Oxygen D small (14” tall) (Silver & Green) Additional Cylinders(Required) Oxygen E small (2’ tall) (Silver & Green) Additional Cylinders(Required) Oxygen M/125 cf. medium (3’ tall) (Only Green) Additional Cylinders(Required) Oxygen H/K large (5’4” tall) (All Green) Additional Cylinders(Required) Oxygen T large (6’ tall) (All Green) Additional Cylinders(Required) Oxygen Aviation (Certified Gas) H (5’4” tall) (All Green) Additional Cylinders(Required)Liquid Oxygen Liquid O2 Oxygen Refill “Medical Grade” Additional Cylinders(Required) 230 large drum (4’ tall) & 3’ in diameter Additional Cylinders(Required) Material: Stainless steel chrome Additional Cylinders(Required)Fire Department & Welding Shop OnlyCompressed Industrial Oxygen Industrial Oxygen H/K Large (5’4” tall) (All Green) Additional Cylinders(Required) Industrial Oxygen T Large (5’10 tall) (All Green) Additional Cylinders(Required) Acetylene Small (3’ tall) (Black or Brown) Additional Cylinders(Required) Medium (3 1/2’ tall) (Black or Brown) Additional Cylinders(Required)Argon Compress T Large (6’ tall) (Black or Brown) Additional Cylinders(Required)ACKNOWLEDGEMENT(Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. Private doctors & clinics. Compressed Oxygen Oxygen D small (14” tall) (Silver & Green) Additional Cylinders(Required) Oxygen E small (2’ tall) (Silver & Green) Additional Cylinders(Required) Oxygen E Grab-&-Go (2’ tall, built-in regulator) (Silver & Green) Additional Cylinders(Required)NF Medical Grade Carbon-Oxide CO2 Carbon Dioxide NF Medical Grade (7 lbs., 2’ tall) (All Silver & Grey) Additional Cylinders(Required) CO2 Carbon Dioxide NF Medical Grade (50 lbs., 5’4” tall) (All Silver & Grey) Additional Cylinders(Required) Medical Grade Nitrous-Oxide Nitrous-Oxide E Small (2’ tall) (Silver & Blue) Additional Cylinders(Required) Nitrous-Oxide H Small (5’4” tall) (All Blue) Additional Cylinders(Required)ACKNOWLEDGEMENT (Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. DME Medical Suppliers. Compressed Oxygen Oxygen C small (9” tall) (Silver & Green) Additional Cylinders(Required) Oxygen M6 small (10” tall) (Silver & Green) Additional Cylinders(Required) Oxygen D small (14” tall) (Silver & Green) Additional Cylinders(Required) Oxygen E small (2’ tall) (Silver & Green) Additional Cylinders(Required) Oxygen F small (2’ ½ tall) (Silver & Green) Additional Cylinders(Required) Oxygen M medium (3’ tall) (Silver & Green) Additional Cylinders(Required) Oxygen H large (5’4” tall) (All Green) Additional Cylinders(Required) Liquid Oxygen Liquid Oxygen Refill - USP Medical Grade (Liquefied, 42 liters drum, 3’ tall, 18” in diameter) Additional Cylinders(Required) Beige top and stainless-steel chrome (HELIOS SYSTEM). Additional Cylinders(Required)ACKNOWLEDGEMENT(Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. For Neurologist, Imaging, Cryo-Stencils Cryobank, Cryo-preservation, and Dialysis Centers. Liquid Oxygen Oxygen E small (2’ tall) – Silver & Green Additional Cylinders(Required) Oxygen H large (5’4” tall) – All Green Additional Cylinders(Required) NF Medical Grade Carbon-Oxide CO₂ Carbon Dioxide NF (7 LBS, 2’ tall) – Silver & Grey Additional Cylinders(Required) CO₂ Carbon Dioxide NF (50 LBS, 5’4” tall) – Silver & Grey Additional Cylinders(Required)NF Medical Grade Nitrous-Oxide Nitrous-Oxide E small (2’ tall) – Silver & Blue Additional Cylinders(Required) Nitrous-Oxide H small (5’4” tall) – All Blue Additional Cylinders(Required)Liquid Oxygen USP Medical Grade Refill (Liquefied, 230L large drum, 4’ tall, 3’ in diameter) – Stainless Steel Chrome Liquid Nitrogen USP Medical Grade Refill (Liquefied, 230L large drum, 3’ tall, 4’ in diameter) – Stainless Steel Chrome Liquid Nitrogen “Hose Rental Replacement” (Liquefied, 3’ long, stainless steel chrome, Black protected hose cover) ACKNOWLEDGEMENT(Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. For Night Clubs, Bars, Outdoor concert, and Restaurant. Carbon Dioxide (CO₂) CO₂ (w-Siphon, Food Grade, 20 LBS, 3’ tall) – Grey or Black Additional Cylinders(Required) CO₂ (No-Siphon, Food Grade, 20 LBS, 3’ tall) – Grey or Black Additional Cylinders(Required) CO₂ (w-Siphon, Food Grade, 50 LBS, 5’4” tall) – All Grey Additional Cylinders(Required) CO₂ (No-Siphon, Food Grade, 50 LBS, 5’4” tall) – All Grey Additional Cylinders(Required)Compressed Nitrogen Nitrogen (H Size, 5’4” tall) – All Black Additional Cylinders(Required) Nitrogen (T Size, 6’ tall) – All Black Additional Cylinders(Required)Liquid Nitrogen Food Grade Refill (Liquefied, 230L large drum, 3’ tall, 4’ in diameter) – Stainless Steel Chrome Liquid Nitrogen “Hose Rental Replacement” (Liquefied, 3’ long, stainless steel chrome, Black protected hose cover) ACKNOWLEDGEMENT(Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. For DermatologistLiquid Nitrogen (Small & Medium Dewars) 20 Liters (Liquefied, 2’ tall) – All Silver Additional Cylinders(Required) 35 Liters (Liquefied, 2’ to 3’ tall) – All Silver Additional Cylinders(Required) 50 Liters (Liquefied, 4’1/2 tall) – All Silver Additional Cylinders(Required)Liquid Nitrogen (Large Dewars) Medical Grade Liquid Nitrogen Refill (Liquefied, 230L large drum, 4’ tall, 3’ in diameter) – Stainless Steel Chrome Additional Cylinders(Required)Compressed Oxygen Oxygen E (Small, 2’ tall) – Silver & Green Additional Cylinders(Required) Oxygen H (Large, 5’4” tall) – All Green Additional Cylinders(Required)ACKNOWLEDGEMENT(Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. For industrial welding, electronics, aviation, automotive, applications Compressed Oxygen Oxygen H (Large, 5’4” tall) – All Green Additional Cylinders(Required) Oxygen T (Large, 6’ tall) – All Green Additional Cylinders(Required)Acetylene Acetylene (Small, 3’ tall) – All Black Additional Cylinders(Required) Acetylene (Medium, 3’ 1/2 tall) – All Black Additional Cylinders(Required)Argon Compress Argon T (Large, 6’ tall) – All Black Additional Cylinders(Required)Nitrogen NF Grade Nitrogen NF Grade H (Large, 5’4” tall) – All Black Additional Cylinders(Required)Liquid Nitrogen Industrial Nitrogen (Liquefied, 10L, 1’ tall) – All Silver Additional Cylinders(Required) Industrial Nitrogen (Liquefied, 35L, 4’ tall) – All Silver Additional Cylinders(Required) Industrial Nitrogen (Liquefied, 50L, 4’1/2 tall) – All Silver Additional Cylinders(Required) Industrial Grade Liquid O2 Oxygen Refill (230L Large Drum, 4’ tall, 3’ diameter) – Stainless Steel Chrome Additional Cylinders(Required)Compressed Helium Industrial Helium U.H. Purity 99.9% H (Large, 5’4” tall) – All Yellow Additional Cylinders(Required)ACKNOWLEDGEMENT(Required) I agree to order additional cylinders, and understand that the extra cylinders will be added to my next monthly rental invoice. Emergency Order HandlingDo you need Same-Day or Weekend Delivery?(Required) Yes No Warning Message 🚨 An emergency fee of up to $264.00 will be added to your order for same-day or weekend delivery. However, this amount may vary depending on your service area, and may also be discounted according to the terms of your contract agreement.(Required) I agree to the emergency delivery fee. Order Tracking ConsentWould you like order tracking updates? Yes No Email(Required) Phone(Required)
