Inventory Request Form

Full Name (requester)

First NameLast Name

Name

First NameLast Name

Distributor Name, if applicable

Name

First NameLast Name

E-mail (requester)*

Your RSD's email*

Contact Number

Area CodePhone Number

Attn:

Ship-to recipient

Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

When do you need this?

*Please note that our standard shipping policy is three business days for trunk stock.

Purpose of Inventory

Trunk StockConsignment (customer-requires PO/agreement)Loan (customer-requires PO/agreement)

Special Instructions

Products (Select category to expand menu options)

Seg-WAY Disposable Kits$0.01

Seg-WAY Blades (Single-Use)$0.01

Item	Quantity
Seg-WAY Blade, Retrograde 200-1003
Seg-WAY Blade, Antegrade 200-1006
Seg-WAY Blade, Retrograde SHORT 200-1009
Seg-WAY Blade, Retrograde LONG 200-1012

Seg-WAY Trays (Reusable)$0.01

Item	Quantity
Reusable, FULL Upper and Lower Extremity 200-5560-ULCU

Seg-WAY Instruments (Reusable)$0.01

mi-eye 3 Cameras$0.01

Item	Quantity
mi-eye 3 Probe, 0° 95MM WL T300-095
mi-eye 3 Probe, 0° 160MM WL T300-160
mi-eye 3 Probe, 0° with cannula T300-095C
mi-eye 3 Probe, 15° angled/carpal tunnel 120MM WL T315-120
mi-eye 3 Probe, 25° with cannula T325-095C

Tablets$0.01

Item	Quantity
mi-tablet 3 T300-001

Transducers$0.01

Item	Quantity
mi-ultra LR T900-020
mi-ultra CX T900-021

Tenex Health TX System$0.01

Item	Quantity
554-1003-001 TX1 Procedure Pack (Single-1 each)
554-1003-001 TX1 Procedure Pack (Case-1 box of 3 each)
554-2003-001 TX2 Procedure Pack (Single-1 each)
554-2003-001 TX2 Procedure Pack (Case-1 box of 3 each)
554-3003-001 TX-Bone Procedure Pack (Single-1 each)
554-3003-001 TX-Bone Procedure Pack (Case-1 box of 3 each)
TX System Console (Trunk Stock)

Total $0.00

If the item is not listed above, please let us know what you need, and the quantity requested.

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