Capital Purchase Program Bundle Options

"*" indicates required fields

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*

This field is hidden when viewing the form

Program*

This field is hidden when viewing the form

Date of Rezum Trial*

Date of Next Procedure*

No date

No date at this time

Type of Package*

Rezum 90-Day Evaluation/Purchase Package

	Model:	90 Day Evaluation:	Purchase Price:
Scope	IEC 30-0515-00	Free	$1,995.00
Total		Price after Evaluation	$1,995.00

Rezum 90-Day Evaluation

	Model:	90 Day Evaluation:
Scope	IEC 30-0515-00	Free
Total		Price after Evaluation

Rezum Purchase Package

	Model:	Price:
Scope	IEC 30-0515-00	$1,995.00
Total		$1,995.00

Quantity*

This field is hidden when viewing the form

Quantity*

Limit 1 for 90-Day Evaluation

Please enter a number from 1 to 1.

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.

This field is hidden when viewing the form

Agreement Checkbox*

I agree to the above terms and conditions and have the authority to sign on behalf of the practice.

Form Completed By*

Signature*

*Limit 1 for 90-Day Evaluation

Looking for additional visualization equipment?

View Bundle Options

Capital Purchase Program Bundle Options

All Storz 27005 BA for $495 are sold out.

Rezum 90-Day Evaluation/Purchase Package

Rezum 90-Day Evaluation

Rezum Purchase Package

Looking for additional visualization equipment?