Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Checkbox *

Epi-Faith Evaluation Facility Commitments:

I have notified appropriate staff at my health care facility of the planned Epi-Faith evaluation, and all facility requirements to initiate the evaluation have been met.

I am requesting a no-cost Epi-Fatih evaluation because I am interested in purchasing Epi-Faith or requesting that my facility or company purchases Epi-Faith..

Checkbox *

Epi-Faith Pre-Evaluation Period Commitments:

I will ensure that only myself and no more than two additional clinicians evaluate Epi-Faith during the evaluation period.

To gain proficiency with Epi-Faith and make an informed assessment of its utility, I will ensure all clinical evaluators use Epi-Faith at least five (5) times each.

I understand the Epi-Faith is cleared by FDA as single use-only products and will not be re-used.