Vendor Form 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*One time costMonthlyAs usedOtherDiscounted Product Costs*Is the discount ongoing or one time?*OngoingOne timeWill this produce revenue for the practice?*YesNoWill this product/service save money for the practice?*YesNoPlease 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. Δ
