Chesapeake Medical Products, Inc

Customer Product Usage Profile

Your Name:

Hospital/Facility:

Facility Address:

City:

State:

Zip Code:

Country:

Phone Number:

Fax Number:

E-mail:

Type of splints made:

Static Dynamic Fracture Brace

Number of splints made in department per month:
Number of staff making splints:

Would like:
In-Service Workshop

Please assist us in providing you with the appropriate samples, by selecting
from the list below, those products which you are currently using in your facility.

Products Currently Used: (check all that apply)
Elastic:	Plastic:
Orfit Soft	NCM Clinic
Orfit Stiff	NCM Clinic D
Aquaplast Blue Strip	Polyform
Aquaplast Orig.	Kay Splint Basic I
Aquaplast-t	Orthoplast II
Aquaplast Watercolor	LMB-Drape
NCM Encore
Kay-Plast	Rubber-Like/Rubber:
LMB-Flex	Ezeform
Prism	Synergy
Omega Max	NCM Spectrum
Omega Plus	Kay-Splint Basic III and Colors
	Kay-Prene
Plastic/Rubber-Like:	Orthoplast
NCM Preferred	Kay-Splint Basic IV
Polyflex II (Sansplint XR)	Sansplint
Kay-Splint Basic II and Colors	LMB-Royal
LMB-Blend