Contact Information First Name * Last Name * Organization Position Email * Phone * Street Address City Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Click Here for X-LineIf you are interested in purchasing or getting samples of X-Line, please fill out the following information. For X-Grid, please see the collapsible form above. Number of New Patients How many new patients does your clinic receive for CT simulation each week? -None-0-5 Patients5-10 Patients10-20 Patients20-30 Patients30+ Patients Obese Patients Of these patients, how many are obese? -None-0-5%5-10%10-15%15-20%20-25%25-30%>30% Make of CT Simulator What is the make and model of the CT simulator(s) that your clinic uses? Information Package Please select whether you would like to obtain an informational package (including a sample) or to place an order. Informational Package (including a sample) Place an Order Number of Boxes In Order If you are placing an order for X-Line, how many boxes would you like? (Note: Each box contains a 50 foot roll of X-Line, which is good for approximately 5 patients) Click Here for X-GridIf you are interested in purchasing or getting samples of X-Grid, please fill out the following information. For X-Line, please see the collapsible form below. Procedures Used With Which procedures would you like to incorporate X-Grid into? Spinal Thoracic Vascular Orthopaedic Trauma Foreign Bodies Number of Selected Procedures How many of the selected procedures does your clinic perform each week? -None-0-5 Procedures5-10 Procedures10-15 Procedures15-20 Procedures20-25 Procedures25-30 Procedures30+ Procedures Information Package For X-Grid Please select whether you would like to obtain an informational package (including a sample) or to place an order. Informational Package (including a sample) Place an Order Samples are limited to medical practitioners only. Please let us know if you are interested in performing any clinical testing. Once you submit the form, we will contact you within 2 business days to confirm your order information and to process payment (if applicable). Comments or special instructions
