NEW ACCOUNT REGISTRATION | BiPAD Surgical

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:

SPID

*Required Information

Facility Name

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

Facility Website URL

Federal Tax ID

Facility Type

For Profit

Not For Profit

Address 1

Address 2

City

ZIP

SHIPPING ADDRESS:

Receiving Facility Name (if different from facility name)

Attention to

Shipping Address 1

Address 2

City

ZIP

Contact Name

Last Name

Title

Phone No.

State Org/Charter ID/License/ SS#

PURCHASING DEPARTMENT:

Contact Person Name

Title

Phone No.

BILLING INFORMATION:

INVOICES SENT Attention to

Billing Address 1

Billing Address 2

City

ZIP

Billing Department Director Name

Title

Phone No.

State Org/Charter ID/License/ SS#

EIN

UTILIZATION INFORMATION

GENERATORS:

Medtronic/Valleylab-compatible

Codman/Malis-compatible

Other

# Medtronic/Valleylab-compatible

# Codman/Malis-compatible

Other, please specify

# Other generator

# of OR's:

In-Patient #

Out-Patient #

Off-Site #

Affiliated Facilities #

Other #

O.R. MANAGER

O.R. MANAGER Name

Phone No.

CENTRAL SUPPLY

Contact Person Name

Phone No.

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)

Pay by Purchase Order

Pay by Credit Card

Pay by check per invoice

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

(Terms: Net 30)

COMMENTS

SIGNATURE

DATE

Thank you. Your account registration has been received. We will contact you shortly. If you have any questions, please call 1-888-635-6381

PDF

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.)

SHIPPING ADDRESS:

PURCHASING DEPARTMENT:

BILLING INFORMATION:

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)

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