Rainbow Latex Free Tubing and Mini Loops Sample Form

Name *

Company Name *

North Coast Account #

Title *

Email *

Phone *

1. Do you or your clinic currently provide exercise tubing or band loops to your patients? *

Yes, we give them awayYes, we give them one and suggest they buy moreNo, we suggest they purchase on their own

2. Are you willing to pay a premium price for a latex-free variety of exercise tubing or band loop? *

Yes, absolutelyYes, as long as the quality is good and the price is reasonableNo, prefer the Natural Latex variety as Natural Latex has superior stretch characteristics

3. Estimate how many patients are seen by your clinic each week could benefit from Exercise Tubing *

Less than 10More than 10, less than 25More than 25

4. Estimate how many patients are seen by your clinic each week could benefit from Exercise Band Loops *

Less than 10More than 10, less than 25More than 25

5. We’ll send you a sample pack that includes all levels of Rainbow™ Latex Free Tubing. For the Rainbow™ Latex Free Mini Loops, which sample would you like to receive? *

Level 1 - 3 - Light Pack (Orange, Pink, Green)Level 3 - 5 – Heavy Pack (Green, Blue, Purple)

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Rainbow Latex Free Tubing and Mini Loops Sample Form

Rainbow™ Latex Free Exercise Tubing & Mini Loops Free Sample Form

Verification

Hand Therapy

Physical Therapy

Occupational Therapy

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