First Name

Last Name

Hospital Name

Title/Position at Hospital

Hospital Email Address

Phone Number

Did you see the MicroCool™ products at a trade show? Did you see the MicroCool™ products at a trade show? Yes No

Please indicate which product(s) you would like us to follow up with you on. Please indicate which product(s) you would like us to follow up with you on. MicroCool® Refrigerator MicroCool® Procedure Cart MicroCool® Microstand MicroCool® Nightstand MicroCool® Malignant Hyperthermia Cart RRU®– All-In-One OB Hemorrhage System IV Blanket™

Would you like us to provide you with an on-site demonstration of our product line? Would you like us to provide you with an on-site demonstration of our product line? Yes - MicroCool® Refrigerator Yes - MicroCool® Procedure Cart Yes - MicroCool® Microstand Yes - MicroCool® Nightstand Yes - MicroCool® Malignant Hyperthermia Cart Yes - RRU®– All-In-One OB Hemorrhage System Yes - IV Blanket™

Would you like a live webinars or phone conference to share with us your current needs and provide us with questions to answer for you? If so, please provide us with two dates and times that work best for you and we will schedule the webinar/phone call. Please allow 48 business hours from submital for your webinar/phone call to be scheduled.