(503) 521-7669 info@impactmedicalco.com

Customer Sign Up

For you convenience Impact Medical has provided this customer sign up sheet. Once completed and submitted, Impact Medical will respond with a customer number that is exclusive to your facility. This will allow you to begin the ordering process. Thank you for selecting Impact Medical.

Fields marked with a * are required.

Section I: Contact Information
Section II: Business Information
Section III: Owners/Officers Information
    1. Name
    2. Title
    1. Name
    2. Title
Section IV: Trade References
Section V: Authorized Users of this account (Only persons listed here will have the ability to purchase on this account)
    1. Name
    2. Title
    1. Name
    2. Title

By entering my name below I hereby authorize the above list (Section V) of names as Authorized Account Users for the above listed (Section I) company's commercial charge account. By submitting this document I understand that I will be responsible for all charges applied to this account by any of the above named persons. The information given is warranted to be true and Applicant authorized Grantor to investigate said information. Applicant agrees to pay all collection fees and court costs incurred if it is necessary to seek legal action on the above account.

    1. Name
    2. Date

If you prefer to submit this form via fax or email, click here to download a copy. (PDF)

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