MDI/Product Search Request Form

Medical Product Search On-line Request Form
To have our Research Specialists search for your requested product, it is required that all the fields below are completed. And remember, the more product detail that you provide, the faster our researchers can locate your products.
My Search Request is:
Type of Product:
Description:
Your Company Name:
MDI# (if member):
Contact Name:
Address:
Phone, Fax:
E-mail:
	Please send my search results via E-mail Fax OR call 800-542-1119
	I am a ProfitBuilder Suite subscriber so my search request is FREE!
	I am not a ProfitBuilder Suite subscriber so after a successful search result is sent to me, please charge the $39 searching fee to my: Visa MasterCard American Express
	I am a medical supplier interested in becoming a ProfitBuilder Suite subscriber, please send me more information.
Cardholder's Name:
Address:
Card#:
Expires:
Signature:	(If faxing request, print this page and sign in the area below.)


You can also submit request by printing your completed form and faxing it to us at 215-942-8729.
MDI does not guarantee the accuracy or completeness of the information provided, including, without limitation, the addresses, telephone numbers, the availability, or prices of the products, and shall not be liable for any resulting claim, damage or loss caused or said to be caused by reliance on the information provided. MDI also does not recommend products or the use of any product for any particular purpose.