Capital Purchase Program Bundle Options

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Name*

Company*

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Boston Scientific Territory Manager*

Phone*

Email Address*

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Program*

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Date of Rezum Trial*

Date of Next Procedure*

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Type of Package*

Bundles*

Bundle Option A

Please allow a minimum of two weeks for products to ship.

Olympus	Model:	Price:
Monitor	21" Medical Grade Monitor	$1,500.00
Processor	Olympus Processor	$4,500.00
Camera	OTV S7 PROH-HD-L08E	$7,500.00
Scope	IEC 30-0515-00	$1,995.00
Total		$15,495.00

Storz	Model:	Price:
Monitor	21" Medical Grade Monitor	$1,500.00
Processor	222201011U	$12,800.00
Light Source	LED Portable Battery Operated Light	$275.00
Camera	22220055	$3,995.00
Scope	IEC 30-0515-00	$1,995.00
Total		$20,565.00

Stryker	Model:	Price:
Monitor	21" Medical Grade Monitor	$1,500.00
Processor	1288-010-000	$4,995.00
Light Source	LED Portable Battery Operated Light	$275.00
Camera/Coupler	1288	$1,500.00
Scope	IEC 30-0515-00	$1,995.00
Total		$10,265.00

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Quantity*

Bundle Option B

Please allow a minimum of two weeks for products to ship.

Olympus:	Model:	Price:
Camera	OTV S7 PROH-HD-L08E	$7,500.00
Light Source	LED Portable Battery Operated Light	$275.00
Scope	IEC 30-0515-00	$1,995.00
Total		$9,770.00

Storz	Model:	Price:
Camera	22220055	$3,995.00
Light Source	LED Portable Battery Operated Light	$275.00
Scope	IEC 30-0515-00	$1,995.00
Total		$6,265.00

Stryker	Model:	Price:
Camera/Coupler	1288	$1,500.00
Light Source	LED Portable Battery Operated Light	$275.00
Scope	IEC 30-0515-00	$1,995.00
Total		$3,770.00

Choose Package*

Quantity*

Payment Terms — Purchase

Payment is required prior to shipment. Equipment will not ship until one of the following is received and approved by Total Scope, Inc.: (1) a valid Purchase Order from an approved institution, or (2) payment in full by credit card, ACH, or wire transfer. A member of our team will contact you after submission to arrange payment. Orders will be held — not shipped — until payment terms are satisfied.

Purchase Order Number

Preferred Payment Method

Evaluation Terms — Credit Card Hold Required

A credit card authorization is required to secure this evaluation. Equipment will not ship until credit card information has been provided and authorized by Total Scope, Inc. A member of our team will contact you after submission to securely collect your credit card information by phone. Your card will NOT be charged at the time of the trial. Your card will only be charged the full bundle value if: (a) the equipment is not returned at the conclusion of the evaluation period, (b) equipment is returned damaged beyond normal wear and tear, or (c) no purchase order is issued at the conclusion of the trial.

Thank you for choosing Total Scope, Inc. for your Rezum Capital Evaluation. As per your request the trial products you have requested will be provided to you for use while trialing the Rezum product.

To the extent that the Evaluation Period lasts longer than 90 days, Total Scope is required to disclose the value of the Evaluation Equipment under the U.S. Physician Payment Sunshine Act. Or in the event that Customer has not purchased and is still in possession of the Equipment after ninety (90) days, the Customer will be charged and invoiced, and shall pay, a Two Hundred Fifty ($250) monthly rental fee for the period following the ninety (90) days and continuing until such time as the Equipment is purchased by the Customer or returned to Total Scope.

Customer will be responsible for any damage outside of normal wear and tear on all evaluation products while it is in your possession. You will not be responsible for any evaluation products that are damaged upon receipt (please contact us immediately).

Please retain all shipping materials during the trial in the event the product(s) need to be returned.

Thank you for choosing Total Scope, Inc. for your Rezum Program. As per your request the trial products you have requested will be provided to you for use while trialing the Rezum product.

To the extent that the Evaluation Period lasts longer than 30 days, Total Scope is required to disclose the value of the Evaluation Equipment under the U.S. Physician Payment Sunshine Act. Or in the event that Customer has not purchased and is still in possession of the Equipment after thirty (30) days, the Customer will be charged and invoiced, and shall pay, a Two Hundred Fifty ($250) monthly rental fee for the period following the thirty (30) days and continuing until such time as the Equipment is purchased by the Customer or returned to Total Scope.

Please retain all shipping materials during the trial in the event the product(s) need to be returned.

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Agreement Checkbox*

I agree to the above terms and conditions, including the payment and credit card authorization terms, and have the authority to sign on behalf of the practice. I understand that no equipment will ship until payment terms (purchase) or credit card authorization (trial) have been satisfied.

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