Repex Table Upholstery Order

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User display name & email

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Order ID

Name*

First Last

Email*

Phone*

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Payment method*

Credit card purchase: Select this option to place an order and pay with your credit card. We are no longer accepting purchase orders with Net 30 terms and all orders must be placed using this option.

Create a quote only: Select this option to build a quote that will be emailed to you. No payment is required and no order will be placed.

Credit card purchase

Create a quote only (no payment required)

PO Number

A purchase order (PO) number is not required but can be provided as a reference.

Upload PO

If you have a copy of the PO, please upload it here.

Drop files here or

Max. file size: 50 MB, Max. files: 1.

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Bill To:

For example, your Hill dealer account or a hospital name.

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Billing Address

Same as shipping address?

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Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Serial Number*

You'll find it on the front of the base skirting of your Hill table or chair.

IMPORTANT: For tables manufactured before the year 2000 (generally serial numbers that begin with 87 through 99), we may require additional information from you when ordering full cushions instead of covers only. We will reach out via email once your order is placed if we require additional measurements or pictures.

Do you have a picture of your table?

Each order is checked for accuracy based on your specific table, so providing a picture will expedite the process of activating your order.

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Vinyl Type*

Standard

Finesse

Vinyl color*

Matching original color?

Are you matching your original color or getting a new color?

Matching my original color

Getting a new color

Table width*

26"

Arm Rests

Arm rests are sold as a set (left and right).

Arm Rests

Arm rests are sold as a set (left and right).

Head Cushion

Main Upper Cushion

Main Lower Cushion

Ankle Cushion

Order notes

For example, do you want a different foam density on any of your cushions? Does your table have a custom feature we should know about?

PA Sales Tax Exempt

Check this box if you are exempt from Pennsylvania sales tax. If you check this box, we may reach out & require proof of exemption. If you are not exempt and you check this box, your order will be cancelled.

Yes, I am exempt from Pennsylvania sales tax

Total

Pennsylvania Sales Tax

$0.00

Please review your order:

Customer Info

Name: {Name (First):21.3} {Name (Last):21.6}
Email:
Phone:

Shipping Address:
{Shipping Address (Street Address):25.1}
{Shipping Address (Address Line 2):25.2}
{Shipping Address (City):25.3}, {Shipping Address (State / Province):25.4} {Shipping Address (ZIP / Postal Code):25.5}

Payment method: {Payment method:46}

Order Info

Serial number: {Serial Number:35}

Vinyl type: {Vinyl Type:17}
Vinyl color: {Vinyl color:16}
Matching original color? {Matching original color?:55}

Table width: {Table width:20}

Order notes:
{Order notes:56}

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Terms & Conditions

By checking the box below, I agree that all information I have entered is correct. I have measured my existing table and verify that the size and color choices I have entered are correct. I understand that Hill Laboratories will custom manufacture each cushion or cover according to the specifications I have entered and that no exchanges will be accepted.

I agree

Terms & Conditions*

I agree that all information I have entered is correct. I have measured my existing table and verify that the size and color choices I have entered are correct. I understand that Hill Laboratories will custom manufacture each cushion or cover according to the specifications I have entered and that no returns or exchanges will be accepted.

I agree

Phone

This field is for validation purposes and should be left unchanged.