Blue Diamond Dry Needles Sample Request

Name *

Company Name *

North Coast Account #

Title *

Email *

Phone *

1. Are you certified to perform Dry Needling? *

YesNo

2. If yes, and you find the Blue Diamond™ Dry Needles to be superior in quality and value, as compared to what you're currently using, will you switch to Blue Diamond™ Dry Needles? *

YesNo

3. Estimate your monthly usage of Dry Needles: *

Less than 5 boxes5 - 10 boxes10 boxes or more

4. Where do you purchase your Dry Needles from? *

LhasaPerformance HealthNorth Coast MedicaliDryNeedleOther

5. What are you paying for a box of 100 Dry Needles? *

More than $20Between $10 - $20Less than $10

6. What brand of Dry Needles do you currently use? *

MyotechiDryNeedle®Seirin® J-TypeOther

Other Distributor:

Other Dry Needle Brand:

7. Do you see value in standardizing to a single brand of Dry Needle, if that brand has all the sizes you would use? *

Yes, absolutelyYes, if the price were rightNo, I prefer to use multiple brands

8. Please select a needle size you would like a sample of:

0.16mm x 13mm0.25mm x 40mm0.30mm x 75mm0.18mm x 13mm0.30mm x 40mm0.25mm x 100mm0.20mm x 13mm0.25mm x 50mm0.30mm x 100mm0.22mm x 13mm0.30mm x 50mm0.40mm x 100mm0.25mm x 13mm0.25mm x 60mm0.25mm x 125mm0.25mm x 30mm0.30mm x 60mm0.45mm x 125mm0.30mm x 30mm0.25mm x 75mm

Mailing Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Samples are intended for healthcare professionals only.

Blue Diamond Dry Needles Sample Request

Blue Diamond™ Dry Needle Free Sample Form

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