Q1 2021 MEDICAL PROMOTION REDEMPTION FORM – USA & CANADA

INSTRUCTIONS:
- Fill in ALL fields.
- ALL information must be completed in order to receive promotional item per “Sunshine Act” requirement.
- Scan your invoice, save as a jpg or pdf, and submit it using the option in the form below.
- This form must be submitted no later than April 30, 2021.
USA and Canada promotion only.
Your Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
Specialty*
Area of Interest*
Practice/Hospital Name*
Please Choose Your Country*
Address*
Street Address Address Line 2 City State ZIP / Postal Code
Phone*
Email*
Serial Number(s) on Unit*
note: to enter multiple units, please separate each number with a comma
Model Number(s)*
note: to enter multiple units, please separate each number with a comma
Invoice Number(s)*
note: to enter multiple units, please separate each number with a comma.
Attach a Copy of Your Invoice(s)*
Drop files here or

Accepted file types: jpg, jpeg, pdf.
note: jpg or pdf Image Format Required. Multiple images may be uploaded
Physician State of Licensure and License Number*
NPI Number*
My Sales Rep/ Distributor is*
Any additional notes?
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