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CONTACT INFORMATION
First Name
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Company / Facility Name
Title / Role
Phone Number
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Preferred Method of Contact
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FACILITY DETAILS
Type of Facility
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Clinic
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Number of Providers at Facility
Facility Location
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EQUIPMENT NEEDS
What type of equipment are you looking for?
Exam Tables
Ultrasound Machines
EKGs
Vital Sign Monitors
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X-Ray Systems
Surgical Lights
Patient Beds
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Quantity Needed
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New or Refurbished Preference?
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When do you plan to purchase?
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PROCUREMENT & LOGISTICS
Do you need delivery and installation services?
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Do you have a purchasing department or GPO contract?
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Are you interested in financing options or lease-to-own?
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Additional Notes / Special Requirements