Get Medical Device Authorization
In order to process your request in a timely manner the following information is required. By signing and submitting this form it allows your organization to purchase Medical Devices under the supervision of a medical practitioner. A Medical Device is classified as a device which requires direct supervision by a medical practitioner and/or a label which may be associated with the product reflecting Caution or RX Only . Date: Customer Name: Account Number: Ship to address: City, Sta.
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