Place an order for medical equipment rental

Equipment info
Kind*
If "other" please specify
Number of units*
Kind
If "other" please specify
Number of units
Kind
If "other" please specify
Number of units
Study info
Sponsor*
Study nr. (internal / on invoice)*
Study nr. (Sponsor) - if different
Site nr.*
Minimum rental period*
Site / Delivery address info
Hospital / Institute*
Department
Address*
Postal code*
City*
State
Country*
Tel. of the contact at the site*
Fax
Contact person at the site*
E-mail address*
Ordering party info
Company name*
Ordered by (name)*
E-mail address*
Requested Shipment Date
Date Format: DD dash MM dash YYYY
Purchase/Order number
Remarks
Remarks
1) At MediCapital Rent we will do our best to meet your requested shipment date. This date is not a delivery date.
2) If applicable

MediCapital Rent