Please Check Your Location and Complete Requested Information
| _____Walsh Medical Arts Offices |
_____Rancho Springs Hospital |
| _____Rancho Springs Medical Offices |
_____Rancho Springs Hospital – Emergency Room |
| _____Stater Brothers
Shopping Center |
_____ Hancock Ave. Medical Center |
| _____ Crossroads
Corporate Center |
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| Suite
Number |
Phone
Number |
| Contact
Person |
Fax
Number |
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| Request Order Delivery |
Day |
| |
Time |
| Sandwich Selection and |
Type of Bagel or Bread | Check the Condiments that you would like or write Easy or Heavy if You Would Like More or Less Than the Regular Amount. | |||||||||
| Deli / Sub/ Cheese Melt or Tuna Melt, etc. | Must |
Mayo |
Italian Dressing. | Lettuce |
Tom |
Onion |
Swiss |
Cheddar or Provolone |
Avocado
|
Bacon | |
| Example |
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| Tuna Melt |
Sour Dough Bagel |
x |
x |
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| Salad Selection | Garden Salad | Garden Salad w/ Chicken Salad | Garden Salad w/ Tuna Salad | Potato Salad | N/A |
| # Ordered | |||||
| Dressings | Ranch | Italian - No Fat | Italian | Raspberry Vinaigrette | |
| # Ordered |
| Chip Selection | Lay's Classic | Lay's BBQ | Poor Brothers Jalapeno Chips | Baked Lay's | Baked BBQ | Baked Sour Cream | |
| # Ordered |
Soft Drinks - Cans
| Drink Selection | Coke | Diet Coke | 7UP | Dr. Pepper | Monster Energy | Bottled Water | Nantucket Nectars |
| # Ordered |
Pastries
| Pastry Selection | Cinnamon Roll |
Croissant |
Brownie |
Apple Turnover |
Cherry Turnover |
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| # Ordered |