This is a Free 30 Day Trial. The Trial Pack Includes:

One Kumar PRE-VIEW Cholangiography Clamp: This Clamp Must Be Returned or Purchased After 30 Days.

Three Free Kumar PRE-VIEW Cholangiography Catheters

A Procedure DVD

Instructions for Use, Clamp Sterilization and Cleaning, Price info.

All fields are Mandatory Except P.O. Number

Contact Information
Name of Surgeon:
Your Name:
Your Title:
Your Phone:
Your Fax:
Your EMail:
Please tell us how you heard about us and any comments: Maximum 5 lines  (60 characters per line)
Hospital Name:
P.O. Number: (No dollar value assigned)
Billing Address
Name:
Street Address:
City:
STATE:	Zip Code:
Shipping Address	Check if same as billing:
Name:
Street Address:
City:
STATE:	Zip Code:

Nashville Surgical Instruments - Free Cholangiography Trial Request
THIS FORM MUST HAVE YOUR SIGNATURE.
PLEASE COMPLETE AND PRINT THIS FORM, SIGN AND FAX TO 615-382-4199
WE CANNOT SEND THE TRIAL TO YOU WITHOUT YOUR SIGNATURE

Signature:_____________________________________________________   Date:______________

---