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Full Name*

Account

Clinic/Practice Name*

Address*

City*

State*

Zip*

Email*

Phone

Are You Interested in a Discounted Trail Pack?*

YES

Comments?

How did you hear about this offer?

Approximately how many patients do you see in your practice each week?

My favorite supplier is:

Gill Podiatry

Henry Schein

McKesson

Federated

If your supplier is not listed above, who is it?

I prefer:

to Dispense

to Prescribe

Patient Direct Order

Please verify your request*