For Vendors

Company name*
City and 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*
MM slash DD slash YYYY
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.

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