Norco Big-Grip T-Rocker Knife

Name *

Title *

Company Name *

Email *

Phone *

North Coast Account #

1. Do you and/or your employer buy and resell ADL items to your clients: *

Yes, on occasionNo, never

2. Where do you send your clients to obtain recommended Adaptive Equipment? *

North Coast MedicalAmazon Other

3. Are you familiar with the North Coast Affiliate program? *

Yes, veryYes, somewhatNo, tell me moreNo, not interested

4. Do you find North Coast retail prices for ADL items to be fair and reasonable? *

Yes, very much soUnsure, no opinion

5. Which Norco® branded product lines are you familiar with? (Select all that apply) *

Exercise & FitnessHand TherapyPain ManagementADL ProductsPositioning ProductsNot familiar with Norco products

6. Who do you consider to be your Primary vendor for Rehabilitation Products, Equipment & Supplies? *

North CoastPerformance Health Other

Address

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

Samples are intended for healthcare professionals only.