Dear Surgeon

Thank you for your interest in the Kumar T-ANCHORS*® Hernia Set.

The FREE SAMPLE will be mailed to the Hospital or Surgery Center of your choice.

This is necessary so that we can comply with Hospital Policies.

This Form MUST be Completed by the OR Nurse or the Materials Manager.

We will email you when the FREE SAMPLE is mailed.

*All Fields are Mandatory except PO Number

Hospital or Facility Name: *

Name of Surgeon: *

Your Name: *

PO NUMBER

FREE SAMPLE REQUEST FORM
Kumar T-ANCHORS*® Hernia Set

A Small Company with BIG Ideas

Phone: 615-382-4996 Fax: 615-382-4199

Shipping Address

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Nashville Surgical Instruments

FREE SAMPLE REQUEST FORMKumar T-ANCHORS*® Hernia Set