Vendor Form

Company name
City and State
Representative name
Title
Office Phone Number
Cell Phone Number
Email
Product name
Product description
List two competitors to your product
Pricing Structure (check all that apply)
- Purchase
- Lease
- Rental
- Service fee
Retail Product Cost
Until which date is the discount available
MM slash DD slash YYYY
Pricing structure
Discounted Product Costs
Is the discount ongoing or one time?
Will this produce revenue for the practice?
Will this product/service save money for the practice?
Please describe how the product produces revenue or savings
Notes to the practice from the representative
Thank you for your submission. We will get back to you via email or phone call in the next 5 business days. Please do not call our office until you receive a disposition on our interest level.
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De-Lens Ophthalmics