30-Day Evaluation Agreement

Request a no-charge 30-day evaluation of Eb Med Co surgical instruments. Complete the four steps below and sign to accept the evaluation terms. Our team will confirm the exact instruments with you and send the No-Charge Estimate for signature before anything ships.

Eb Med Co 30-Day Evaluation Agreement

1
Requestor
Information
2
Evaluation
Details
3
Shipping &
Logistics
4
Agreement &
Signature

Requestor Information

Tell us who is requesting this evaluation and where the instruments will be used.

Requestor Type

Hospital

Surgery Center

Sales Representative / Distributor

Select the option that best describes the entity requesting this evaluation.

Hospital / Facility Name

Distributor / Company Name

End-User Facility (where instruments will be used)

The hospital or surgery center this evaluation is being requested on behalf of.

Sales Rep Full Name

Sales Rep Email

Required for all rep notifications.

Sales Rep Phone

Format: (XXX) XXX-XXXX

Facility Address — Street

Facility Address — Line 2

Suite, floor, department, etc.

Facility Address — City

Facility Address — Province

Facility Address — Postal Code

SPD Contact Name

Sterile Processing Department contact who will receive instruments for reprocessing.

SPD Email

SPD Phone

Nurse Manager Contact Name

Nurse Manager Email

Nurse Manager Phone

If you are human, leave this field blank.