ems telemedicine - Rosetta Lt Quotation Request Form


	Request Rosetta Lt Quotation Form: Thank you for your interest in our products and services. Please complete the following form, and we will follow up on your request. If your have an immediate need, please call us toll-free at 877-466-1422. Please indicate total number and models defibrillators, cellphones(and provider, e.g. Nextel, T-Mobile, etc.) and radios (brand and model number) are to be used with the Rosetta Lts.
Name:	(required)
Title:	(required)
Email Address:	(required)
Organization:	(required)
Street Address:	(required)
City/State/Zip:	(required)
Phone Number:	(required)
Best Time to Call:	(required)
How did you hear of us:
Time to Purchase:	(required)
	Please indicate total number of each defibrillator-monitors to be equipped with Rosetta Lt. (indicate "none" if not used)
Total Number of Lifepak 12 defibs:	each
Total Number of Zoll M-Series:	each
Total Number of Zoll E-Series:	each
Total Number of Philips MRx:	each
	Please indicate how many of each cellphone and radio (indicate manufacturer and model of each) are to be used with Rosetta Lt.
Total Cellphones Brand/Model Numbers:
Total Radios Brand/Model Numbers:
Request or Comments:
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