Sales Support

Short-Term Use

Product Request form

Applies to free trials, loans, and event use.

The information in the form below is used by various teams
to ensure proper coordination of the requested demonstration.

Request Details

YOUR INFO

Your Name

Your E-mail

CLIENT INFO

Company/Hospital

TRANSACTION INFO

Priority

Normal

URGENT

Transaction Type

Trial

Loan

Event

Product Line

UVD Model C

GoBe Robot

PTR Robot

Starts On

*To prevent premature pickups and/or event interruptions, robot pickups are scheduled for the day following the end date.

Ends On

PRODUCT DELIVERY

Delivery Address

* The appointed individual listed below will receive a courtesy call from the delivery service provider upon arrival to coordinate delivery. This individual will also serve as the pickup point of contact unless otherwise instructed.

Delivery POC Name

Delivery POC Email

Delivery POC Phone

Deliver by Date
The latest date the item can be delivered

Special Delivery Instructions

Notes/Comments