Vendor Form

Please complete the form below to submit your product or service for consideration by our practice. We review all submissions carefully and will follow up within 5 business days.

Company Name

City and Province/State

Representative Name

Title

Office Phone Number

Cell Phone Number

Email

Product Name

Product Description

List Two Competitors to Your Product

Pricing Structure (check all that apply)

Purchase Lease Rental Service Fee

Retail Product Cost

Until Which Date is the Discount Available?

Pricing Structure

Discounted Product Costs

Is the Discount Ongoing or One Time?

Will This Produce Revenue for the Practice?

Will This Product/Service Save Money for the Practice?

Please Describe How the Product Produces Revenue or Savings

Notes to the Practice from the Representative

Thank you for your submission. We will get back to you via email or phone call in the next 5 business days. Please do not call our office until you receive a disposition on our interest level.