New Customers - U.S. Distributors

  • Fill out the form
  • Submit your completed form
  • We will contact you to confirm details

Account Information



Billing Information






Billing Address







Shipping Information

(leave blank if same as Billing Information)






Shipping Address

(leave blank if same as Billing Address)












Business References

Directions: Please provide as much information as you can for three (3) business references.

Reference #1









Reference #2









Reference #3









Additional payment information

  • Payment terms are NET 30

Additional shipping information

  • We can only ship product to authorized distributors, hospitals, or other medical organizations
  • Shipping charges will be prepaid and added to your invoice unless your company has a UPS, FedEx or other account to which shipping charges can be applied.
  • Unless otherwise requested, orders will ship via ground delivery.
  • Shipments to PO boxes and drop shipments can not be completed.