bioMerieux -- VIDAS D-Dimer CD Request

Thank you for your interest in the bioMérieux CD presentation, "Use of VIDAS D-Dimer Assay for the Evaluation of Venuous Thromboembolism" by Dorothy Adcock, M.D.

Please fill out this short registration form to order your complimentary copy of this unique, interactive video on CD-ROM.

Required fields are indicated by an *

First Name: *
Last Name: *
Academic Title: *
Job Title:
Institution: *
Phone: *
Email: *
Your address is?: *	Inside the United States Outside the United States
Inside the United States
Address: *

City: *
State: *
Zip: *
Outside the United States
Address: *

City: *
State/Province:
Zip/Postal Code:
Country: *
Please provide us with the following information if you are already a bioMérieux customer.
Account Name:
Site #:	Customer #:

I would like to know more about bioMérieux:*	yes no
Please have a customer service representative contact me:*	yes no
Please email me information on new products, special offers, surveys or upcoming events: *	yes no

Other comments: