medical equipment we repair

New Customer

Please fill out the following form and click submit.
A copy of the form will be delivered to our office for processing as well as sent to you for your records.
Company Name*
Federal Tax ID*
The following is for Billing Information
Address*
City*
State
Zip Code*
Phone*
Fax
Email*
Enter Name of Accounts Payable
First Name*
Last Name*
ALL TAX EXEMPT/RESALE ORGANIZATIONS ARE REQUIRED TO PROVIDE US WITH TAX EXEMPT/RESALE CERTIFICATES. IF NOT ON FILE: STATE, LOCAL, AND COUNTY SALES TAX MAY APPLY WHERE APPLICABLE.
The following is for Shipping Information
Address*
City*
State
Zip Code*
County*
Biomed Contact Name
Biomed Contact Phone
Please include me in future contacts.

NOTE: Security Code is case sensitive