Vendor Product Request Form
Areas with the yellow background are required to successfully process your request!
Date: 04/24/2014    
Nature of Request:  New Item(s)     Consignment     1 Time Use   
  For New Items, is a Trial Required?  Yes     No   
If yes, will free samples be provided?  Yes     No   
Facility:  KMC     SMC     GMC     SVMC     GMH
Company Name: Company Phone:
Company Website:
Representative Name: Representative Email:
Representative Phone Number:
Sponsoring Physician:
Physician Phone Number:
Additional Physician: Additional Physician:
Additional Physician: Additional Physician:
Additional Physician:
Master Project Description:

Item Description: Product Catalog Number:
Product EACH Cost: Product Order Packaging:

Item Description: Product Catalog Number:
Product EACH Cost: Product Order Packaging:

Item Description: Product Catalog Number:
Product EACH Cost: Product Order Packaging:

Item Description: Product Catalog Number:
Product EACH Cost: Product Order Packaging:

Item Description: Product Catalog Number:
Product EACH Cost: Product Order Packaging:

Item Description: Product Catalog Number:
Product EACH Cost: Product Order Packaging:
Are there multiple sizes available?  Yes     No   
Clinical Benefit:
  Will there be any additional fee, or cost, associated for equipment or instruments?  Yes     No   
If yes, please explain.
Hard copy of product information available?  Yes     No   
Click Here for pricing agreement requirements.
FDA Approved?  Yes     No   
Proposed Sponsoring Physician Annual Usage:
Product trade out available if necessary?  Yes     No   
Premier Contract available?  Yes     No   
Premier Contract Number: Tier:
CPT:
DRG:

**This submission will not be accessed until a Physician directly requests these products.**
**This submission will expire in 30 business days.**

Your request will be sent by pressing the 'submit' button -