Don’t Waste Another Spray! Swap Out Your Topical Anesthetic Spray For CoolJect® TargetedMist™
CoolJect can only be shipped to licensed healthcare facilities.
Facility/Practice Name:
*
NPI:
Prescription License Number
Physician's Name:
First Name
Last Name
Phone Number:
*
Email:
*
example@example.com
Shipping Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Your Primary Medical Supplier:
*
Who do you purchase medical supplies from?
Topical Anesthetic Being Swapped Out for CoolJect?
*
Please Select
Ethyl Chloride
Pain Ease
CryoDose
Other
Brand Name
If you selected "other" please type in the brand name
Number of Canisters Swapping For CoolJect?
*
Type the number of canisters being exchanged
I certify that I am authorized to make this facility request and that none of the topical anesthetic spray canisters have not expired.
*
Yes
Name
*
First Name
Last Name
Please verify
*
Save
Submit
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