Cordflex Sample Request Form
Name:
*
First Name
Last Name
Email (Usually Work Email if you check it):
*
example@example.com
Phone Number (for Unit/Office or best contact):
Please enter a valid phone number.
Format: (000) 000-0000.
Hospital (Name & City if Big Hospital System):
*
Floor/Unit:
*
Position on Floor:
*
Floor Nurse
Charge Nurse
Nurse Manager/Asst Nurse Manager
Nurse Educator
CNS
CNO/Assistant CNO/C-Suite
Product Purchasing/Materials
Value Analysis
Other
Who would approve new product adoption for your floor/hospital?:
*
Most important for me/my unit, I can see how Cordflex would:
*
Save nurse time
Reduce staff frustration
Help nurses feel safer ambulating patients
Make patient transfers and ambulation more enjoyable
Prevent trips and falls
Prevent line tracing errors
Prevent medical errors
Other
Comments/Questions/Notes/Suggestions:
Submit
Should be Empty: