Request

Request form

Complete this form.

Company Name*
Your Name*
E-mail Address*
E-mail Address(Retype)*
Zip Code	( ex：999-9999 )
Country
Address1*
Address2
Telephone*	( ex：03-9999-9999 )
Fax	( ex：03-9999-9999 )
Mobile phone
Code	17377
Name	Video Gastroscope
Brand	OLYMPUS
Model	GIF-H290Z
Endorsement number	226ABBZX00083000
Status
Price
Comment	HD scope
Specification & Options	Insertion tube 9.6mm Channel size 2.8mm *Working length 1030mm
Configuration
Condition	Patient ready
inquiry*	(1000characters)