Medical Instrument Order Form

If you are experiencing problems submitting this form, please email SAATech@utsouthwestern.edu

Submission Deadline: 1 July 2024

* Required

* Name:

Student ID (if known):

* Phone Number:

* Email:

Orders received by July 1, 2024 will be available for pick-up the first week of August 2024. A University Store team member will contact you via provided email with payment and pick-up instructions.

* I have authorized the University Store to order:

Stethoscope

3M Littmann Cardiology IV Stethoscope ($188.29)

Stethoscope - I already own this item OR will order this elsewhere

Diagnostic Kit

Welch Allyn Diagnostic Set ($785.00)

Diagnostic Kit - I already own this item OR will order this elsewhere

Tuning Forks / Reflex Hammer

(128Hz & 256Hz tuning forks are required.)

Sensory Kit ($38.49)

Kit includes:

128Hz Tuning Fork
256Hz Tuning Fork
Prestige Telescoping Babinski Hammer
Zippered Case

Tuning Forks / Reflex Hammer - I already own a reflex hammer and a 128Hz tuning fork OR will order these elsewhere

Please select the method of payment(s) below:

Credit Card

Financial Aid

Total Cost:

8.25% Tax:

Grand Total:

For students utilizing financial aid, your FAFSA must be submitted before financial aid is officially an approved payment method for this order. Your total aid must exceed the amount due for tuition and fees by at least the amount of this order. If there is an issue with your financial aid award, a financial aid representative will email you. You will be required to respond within the deadlines outlined in that email. If you do not respond, you will have to pay by credit card before the order is released to you.

If all the conditions above are satisfied: 50% of the amount above will be charged to your UT Southwestern student account shortly before your first disbursement of Financial Aid (either summer or fall; depending on when your program begins). This will pay the first half of the charges owed. The remaining amount owed will be charged and paid in the same manner with the spring financial aid disbursement.

Orders received by July 1, 2024 will be available for pick-up the first week of August 2024. A Student Life team member will contact you with further instructions about pick-up during orientation week.

First Fall Term in August, 0.00 (50% total) will be drawn from your financial aid.

Spring Term in January, 0.00 (last 50%) will be drawn from your financial aid.

Notes:

Please review the information you have provided above for accuracy before submission.
Upon clicking on the "Submit Form" button below, your request will be emailed to the University Store for processing.
You will be CC'ed if you have provided a valid email above.
General questions or concerns, please email university.store@utsouthwestern.edu or call 214-648-8095.
Questions regarding Financial Aid, please email financialaid@utsouthwestern.edu or call 214-648-3611.

Please select at least 1 item to submit your order.

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