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	18572
Name	Video Gastroscope
Brand	OLYMPUS
Model	GIF-PQ260
Endorsement number
Status
Price
Comment	Work with CV-260/290/240
Specification & Options	Insertion tube 7.9mm Channel size 2.0mm Working length 1030mm
Configuration
Condition	Patient ready
inquiry*	(1000characters)