Parametrics Medical

Date Created MM / DD / YYYY
Facility Name *

Please input facility name here.
Billing Address (Street)
Billing Address (City)
Billing Address (State)
Billing Address (Zip Code)
Shipping Address (Street)

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Shipping Address (City)

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Shipping Address (State)

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Shipping Address (Zip Code)

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Purchasing Contact Name
Purchasing Contact Phone Number ### - ### - ####
Purchasing Contact Fax Number ### - ### - ####
Purchasing Contact Email
AP Contact Name
AP Contact Phone Number ### - ### - ####
AP Contact Email
Do you own a freezer?
yes no
Can you accept First Overnight deliveries?
yes no
Is the facility tax-exempt?
yes no
Allograft Rep who manages the facility? First Last
Submitted By * First Last
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