To request a quotation, or samples of our plastic tubing or plastic fittings, please fill in the following form as completely as possible.
Fields marked with an asterisk (*) are mandatory.
Would you like a quotation, sample, or both? * Quote Sample Both
Contact Name *
Email Address *
Company Website
Company Name *
# of Employees
Type of Business * Medical Device Manufacturer/OEM Research & Development/Engineering Firm Medical Facility
Description of your Business
Street Address *
City *
State/Province
Country *
Zip / Postal Code
Phone # * (i.e. 555-555-5555)
Intended Market
Estimated Annual Volume *
Type of Tubing or Fitting * Corrugated Collapsible (expandable) Smooth interior corrugated tubing Medical Fittings
Tube Diameter (ID): 10mm 13mm 15mm 19mm 22mm 25mm 38mm Other
If Other, please specify
Length(s) required
Global Part # (if known) or product description (if a new application) Plastic Medical Fittings (reference)
# of samples required *
Material
Comments (Other special testing, packaging, labeling or shipping requirements)
Submission Validity Check: (leave empty)
MD&M WEST
MD&M East
Medica/Compamed