Bed-Check Corporation Distributors -- Request Form

REQUEST FOR QUOTE AND/OR MORE INFORMATION

If you would like to receive a quotation, more product information, or both, please fill out this form and click "submit" at the bottom of the page. You will be contacted within 1-2 business days.


*Designates required fields.
*First Name
*Last Name
Title
*Facility Type	Hospital LTC ALF Hospice Private home Other
*Facility/Org
*Address

*City
*State
*Zip
*Phone
Fax
*Email Address
Does your facility buy through a GPO contract? If so, please identify which one(s):

Products of Interest

Product
Bed Monitors
Approx. Quantity		Model Vr
Approx. Quantity		Classic-Check®
Approx. Quantity		Don't know
Bed Sensormats
Approx. Quantity		IT (30 day warranty)
Approx. Quantity		LT (90 day warranty)
Approx. Quantity		Don't know
Chair/Wheelchair/toilet Monitors
Approx. Quantity		Chair-Check® II
Approx. Quantity		Basic-Check®
Approx. Quantity		Don't know
Chair/Wheelchair Sensormats
Approx. Quantity		IT (30 day warranty)
Approx. Quantity		LT (90 day warranty)
Approx. Quantity		Don't know
Potty-Check® (toilet seat) Sensormats
Approx. Quantity		Potty-Check® (toilet seat) Sensormats

Please add any other questions or comments here: