REQUEST A QUOTE

By completing the following form, MacMed will be able to provide you with a
quotation on any of our products:

Name*
Company or Group name*
Facility name*
Position
State*
Phone*
Fax
Email*
I am interested in:	Mattresses Cushions Pressure Redistribution Chairs Bariatric Range Paediatric Range Podiatry Range Falls Prevention Range Skin Protection Personal Care Range QTY:
Additional comments:
Should you require a quotation on a customised product, please complete the following information:
List the product(s) you would like quoted:
Product dimensions in cm:	Length* Width* Depth*
Weight of patient:	Kilograms
Additional patient information: (Frail, disabled, etc.)
Cover requirements:	Zipper: Welded:
Please advise whether this enquiry would be eligible for any of the following:	Medical Aid Subsidy Scheme  Department of Veteran Affairs  Seniors Card
	* Required

Please note that quotations for customised products will exclude freight/delivery costs