We’ve been on a mission to serve our clients since 1976

Phone

Toll Free: 888.279.3323
Customer Service: 425.556.0544

Email

US: [email protected]
France: [email protected]
Spain: [email protected]
Germany: [email protected]

Address

8415 154th Ave NE
Redmond, WA 98052

Remit to Address

PO Box 74007048
Chicago, IL 60674-7048

GMBH Address

Spilburgstr. 1
35578 Wetzlar

Contact

Request a Call Back

New Customer Form

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Facility/Customer Name*

Phone Number

Fax Number

Address*

Street Address City State ZIP Code

DBA Name

Alternate Phone Number

Alternate Fax Number

Billing Address*

Street Address City State ZIP Code

Ship to Address

(if different than Billing Address)

Street Address City State ZIP Code

Does your facility have its own shipping account? If so, would you like us to ship your orders on your carrier’s account?

Yes

Name of Carrier (i.e., Fed Ex or UPS)

Account Number

Purchasing Contact Name*

Purchasing Contact Email*

Purchasing Contact Phone*

Accounts Payable Contact Name*

Accounts Payable Contact Email*

Accounts Payable Contact Phone*

Email Address for Receipt of Invoicing*

Email Address for Receipt of Statements*

Financial Information

Tax Exempt? If Yes, please upload or email a copy of your State Exemption Certificate, MCT Form, and/or SSUTA Certificate with this form.*

Yes

Upload Tax Exemption Certificate:*

Max. file size: 50 MB.

Does your facility require Purchase Orders?*

Yes

DUNS Number

Facility Type

Business Type

(Corp, LLC, Partnership, Sole Proprietor, Individual)

Federal Tax ID Number (FEIN)*

Officer/Principal Information

Name

Title

Phone

Name

Title

Phone

Sales Agreement

The undersigned agrees to the MST Terms and Conditions available at https://microsurgical.com/terms-quality-regulatory/. All products are sold by MST FOB MST’s shipping point. The undersigned, in consideration for the terms of sale herein and for the extension of credit terms by Microsurgical Technology, Inc., agrees to pay all amounts due within the terms defined as Net 30. Returned checks are subject to a service charge of not less than $30 for each occurrence. Past due payments are subject to customer credit hold and may incur interest charges. If a dispute arises undersigned agrees to pay all items not in dispute within terms. Venue for any collection or legal action will be King County, Washington. Undersigned agrees to reimburse all reasonable costs of collection and bankruptcy proceedings including, but not limited to, legal, arbitration, collection agency, research and service fees.

The undersigned certifies that the information contained above is true and correct and further agree that any changes in ownership, corporate location, officers or form that the business operates under shall be immediately made know to Microsurgical Technology, Inc., via certified US Mail or via email at [email protected]. The undersigned agrees they are authorized to commit to the terms of this agreement.

Authorized Signature*

Signor must be authorized to commit to the terms of this agreement.

Your Name*

Title*

Email*

Phone*

Repair Service Form

Customer Account Name(Required)

Customer Account Number(Required)

Customer Address

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

RMA Contact Name(Required)

First Last

Contact Email(Required)

Phone

Product Details

Part Number(Required)

Lot Number(Required)

Number of Devices(Required)

Was there patient contact/impact?(Required)

Describe the issue(Required)

Complaints Form

"*" indicates required fields

Customer Account Name*

Customer Account Number*

Customer Address*

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

RMA Contact Name*

First Last

Contact Email*

Phone

Product Details

Part Number*

Lot Number*

Number of Devices*

Describe the specific details of the complaint*

Was there patient or user injury?*

Medical/surgical intervention required?*

Date of Event*

Will device(s) be returned?*

Yes

Note: All defective devices MUST be returned. Please specify reason if defective devices are not returned:

Number of devices being returned*

Customer Requests:

Replacement

Credit on account

Customer Feedback

New Customer Form

First time purchasing from Microsurgical Technology? Fill out the new customer form below to get pricing and purchase online.

Go to Form

Repair Services

Have a device that needs repair? Fill out the form below and we will contact you with next steps.

Repairs Form

Concerns

Concerns/Complaints Form

Phone

Remit to Address

Email

Address

GMBH

TrabEx Pro

TrabEx

Trabectome Pack

We’ve been on a mission to serve our clients since 1976

Phone

Email

Address

Remit to Address

GMBH Address

Contact

Request a Call Back

New Customer Form

Financial Information

Officer/Principal Information

Sales Agreement

Repair Service Form

Product Details

Complaints Form

Product Details

Customer Feedback

We would love to hear from you!

New Customer Form

Repair Services

Concerns

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