Request Further Information

Note: Fields in RED must be entered to submit response.

Personal Identification

 

Name* (first & last):	Note: Accented and Tilde characters should be substituted with English characters (e.g. replace é with e)
Degree:	M.D.	Ph.D.	Aud.
	P.T.	O.T.	D.O.	Other Degrees:
	D.C.	R.N.	Au.D.
Company Name*:

Address Location	Business Address Home Address
Address*:

City*:		State*:
Zip*:		Country:
Phone*:		Fax:

Email*:

Information Requested
	Product Literature
	Price Quotation
	Product Specifications
Products of Interest
VIDEO GOGGLES				VIDEO ENG
	RealEyes Monocular					Tower System		Laptop System
	InView Monocular		InView Binocular
ROTATIONAL VESTIBULAR CHAIR SYSTEM 2000				CALORIC IRRIGATORS
	Economical Video		Binocular Video			AquaStar WATER  IRRIGATOR		AirStar AIR  IRRIGATOR
	Micro Centrifuge					Cooling AirStar AIR  IRRIGATOR
COMPUTERIZED POSTUROGRAPHY				ACTIVE HEAD ROTATION
	Balance Quest Dynamic Platform		Balance Check Static Platform			VORTEQ® / DVAT
TIME FRAME Not Specific Urgent 90 Days 6 Months Budget
Additional Information   Question / Comment (Limit 30 lines):
Vestibular Update Request
	Please send me the selected back issues of  Vestibular Update on Interactive CD:
	Balance Disorder Case Studies Judith White, M.D., Ph.D. of Cleveland Clinic Neil Shepard, Ph.D. of University of Nebraska Brian Werner, M.P.T. of Balance Centers of America				2004
	Balance Disorder Case Studies:  Eye Movement Abnormalities Ron Tusa, M.D., Ph.D. of Emory University Neil Shepard, Ph.D. of University of Pennsylvania				2002

 

 

Go Back to Top of Page

Micromedical Technologies
Copyright © 2007 All Rights Reserved