INRAD Sample Request Form

Fill out the form below to request complimentary evaluation samples of any of our disposable medical devices. Only practicing physicians in the USA are eligible for evaluation samples (INRAD devices are RX).

First Name

Last Name

Job Title

Company

Email Address

Phone Number

Product Code(s) Requested

Mailing Street Address

City

State

Zip Code

Comments

Samples Available to Practicing Physicians in the USA (Devices are Rx)

I am a practicing physician

I am requesting on behalf of a practicing physician