Dealer Application / Order Form

Please complete the form below for orders, samples, dealer applications or an inquiry.

We will review your requests promptly. All information received is strictly for the use of Prodaptive Medical Innovations Ltd. in completing an order and/or request. Information will never be used or sold to any third parties. Although we only ask for a few mandatory fields we will need adequate information for fulfillment of any samples and/or dealer applications.

Fields marke with orange are required.

Organization:
First Name: Please enter your first name.
Last Name:
Phone:
Fax:
Email: Please enter your email address.Email address must be valid.
Address:
City:
Province/State:
Postal/Zip:
Country:
Number of STAL Shields:
Number of STAL
Suction Kits:
Please include
2 Free Samples:
I am a: Union Representative
Infection Control Specialist
      Medical Distributor

How did you find us?
Please add any comments you wish to post. This can include details of your business if you are a medical supply company, hospitals, clinics, EMT’s or other types of medical related fields. Also, feel free to simply post a question.
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