Demo Request Form

This form must be filled out completely before the request can be filled.

Accreditation (i.g., CPO, CHT, MD, etc)*

Accreditation Number*

Clinician First name*

Clinician Last name*

Clinician Email*

Clinic

Clinic Name*

Clinic Phone Number*

Country*

Clinic Street Address*

Clinic City*

Clinic Zip Code*

Shipping

Is your clinic address the same as your shipping address?*

Request Details

Date Needed By*Our lead time for demos is 2 weeks. Please select a date at least 48 hours prior to your patient's visit. Please call us at (720) 600-4753 for any exceptions.

Please include any additional comments hereEx: rush orders, etc.