Product Ordering

Make a Credit Card payment

Account details

Hospital Name *

Account Number *

(if you don't know your account number, email csusa@sirtex.com)

Person making payment *

Telephone *

E-mail *

Payment details

Invoice Number *

Amount *

Service Charge (5%)

Total Amount

First name on Card*

Last name on Card*

Credit Card Number *

CVV code *

Expiration Month *

Expiration Year *

Billing details

Billing Address 1 *

Billing Address 2

Billing State *

Billing City *

Billing Zip Code *

SIR-Spheres^® is a registered trademark of Sirtex SIR-Spheres Pty Ltd.

By submitting this Credit Card Payment Form (“Form”), the Customer gives Sirtex Medical, Inc. (“Sirtex”) permission to debit Customer’s account for the amount indicated on or after the indicated date. Such submission constitutes Customer’s acceptance of Sirtex’s Order and Cancellation Policy, a copy of which is available upon request, as well as certification that all required steps (i.e. insurance approval, lab work, etc.) have been performed prior to ordering and that Customer is appropriately licensed to handle the products ordered herein.

Customer certifies they are an authorized user of this credit card and this payment will not be disputed with the applicable credit card company provided the transaction corresponds to the terms indicated herein. If for any reason payment cannot be completed via the credit card provided on this Form, Customer shall be liable for any outstanding balances due.