Optomap Retinal Scan and Imaging Company name City and State Representative name Title Office Phone NumberCell Phone NumberEmail Product name Product descriptionList two competitors to your product Pricing Structure (check all that apply) Purchase Lease Rental Service fee Retail Product Cost Until which date is the discount available MM slash DD slash YYYY Pricing structureOne time costMonthlyAs usedOtherDiscounted Product Costs Is the discount ongoing or one time?OngoingOne timeWill this produce revenue for the practice?YesNoWill this product/service save money for the practice?YesNoPlease describe how the product produces revenue or savingsNotes to the practice from the representativeThank you for your submission. We will get back to you via email or phone call in the next 5 business days. Please do not call our office until you receive a disposition on our interest level.CAPTCHANameThis field is for validation purposes and should be left unchanged.
