Distributor Name
Phone
Email
Geographical Area:
Address
City
State
Zip Code
Current products being used
Product being requested
Is the requested product approved?
Hospital(s)
Note: Account form must be completed before surgeries are scheduled.
Surgeon(s)
What is the pricing/proposed pricing/GPO (if known)
Who will/can do the billing (NAM or Manufacturer)
What is the volume
Is a demo needed/ needed when and return date
Who are we paying (if different than Distributor name)
W9 & Direct Deposit Information Provided
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