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What is the name of this product?
(e.g. Baker’s Gauze)
*
What is it used for?
(e.g. Burn Dressing)
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Describe the product in detail including packaging requirements:
How can we get in touch with you to discuss this product?
*
Name:
*
Title:
*
Hospital:
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Telephone:
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Fax:
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Email:
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or
print
the form and fax to (203) 924-4932
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