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

BiPAD® REQUEST TO TRIAL

IN THE OPERATING ROOM

This is a request for a product for use in a trial during surgery.  We will provide a free product for this purpose. 

 

We will contact the surgical facility to arrange for the surgical trial on your behalf. Please complete the form as all information is usually required to complete this process. 

 

We are happy to know that you want to trial BiPAD® and we look forward to your feedback.

CONTACT INFORMATION:

*Required Information

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SHIPPING ADDRESS:

PURCHASE ORDER INFORMATION:

A $0 Purchase Order is required to send product. Please upload a Purchase Order. 

Please provide Contact Info below if contact info is different than above, for P.O. follow-up.

Upload P.O.
Upload supported file (Max 15MB)

BILLING INFORMATION:

TRIAL DETAILS:

Generators Planned for Use:

Do you need an adapter cord for your machine?

*A Y Adapter is provided complimentary with your trial if needed. If a purchase is made it is yours to keep at no charge. If no purchase is made 30 days after the trial, a charge of $199 will automatically be billed to you unless returned to BiPAD Surgical, 110 Ocean Pkwy, Point Look Out, NY 11569.

Surgeon(s) who will trial BiPAD at your facility:

How did you hear about BiPAD®?

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