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To create innovative solutions that enhance the ability
of surgeons to heal.

BIPAD® ACCOUNT REGISTRATION FORM

Thank you for your business,  BiPAD® SURGICAL looks forward to partnering with you to enhance the OR experience for your staff and your patients.

GENERAL:

*Required Information

(Please complete a set-up form for each facility accessing contracted pricing.)

Facility Type
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SHIPPING ADDRESS:

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PURCHASING DEPARTMENT:

BILLING INFORMATION:

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UTILIZATION INFORMATION

GENERATORS:

# of OR's:

O.R. MANAGER

CENTRAL SUPPLY

Please provide your new product review and acceptance protocol. Fax to (516) 738-4948

Payment Options: (Payment Terms: Net 30 days, 1.5% finance charge beyond 30 days)

Please fax your facility's PO Terms and Conditions Document to 1 (516) 738-4948

(Terms: Net 30)

SIGNATURE