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Name

Email Address

Company / Facility Name

City

State StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Phone Number

I am requesting information for: I am requesting information for: Acute Care Facility (Hospitals, etc.) Non-Acute Care Facility (Skilled Nursing, Rehab, etc.) Home Care Organization (Visiting nurses, hospital transportation providers, etc.) Personal Use (self or family member) Other (Please specify in message)

Feeding Tube Type Feeding Tube Type NG, NJ G, PEG J, PEG-J Avanos MIC GJ Avanos MIC-KEY GJ Applied Medical Technology (AMT) G-JET GJ Applied Medical Technology (AMT) Traditional G-JET GJ

French Size (Fr)

Tube Length (cm or in)

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