Product Sample Form

Physician Name (First/Last) *

Facility Name/Dynamics Opportunity *

Facility Address *

Facility City, State, Zip *

Facility Contact Name *

Facility Contact Phone *

E-Mail *

Shipping Address

Shipping Address

Shipping City, State, Zip

Shipping Contact Name

Shipping Contact Phone

Requested Item *

Quantity

Selected Value: 1

Requested Item

Quantity

Selected Value: 0

Requested Item

Quantity

Selected Value: 0

Requested Item

Quantity

Selected Value: 0

Sample Purpose

Provided from REP Stock?

Sales Rep Name

Sales Rep Email *

Comments / Special Shipping Instructions

Clinical Training Completed

Terms *

The recipient agrees the quantity of product provided at no charge does not exceed the amount reasonably necessary to appropriately evaluate the product. Furthermore, the recipient shall use the product solely for product evaluation purposes, and shall not resell or redistribute the product, and in no event charge any patient or any federal, state, or commercial payer for any of the sample product.

Printed Name *

Date *

Please see package insert (IFU) for the complete list of indications, warnings, precautions and other important medical information.

All orders are subject to ETS Terms and Conditions available under www.ets123.com/gtc and will be provided to Recipient upon request.

Thank you for your business!