Nerve Block Needle Archives

Cryo Painblocker™: Setting a New Standard in Cryoneuroablation - EXPLORE

2022 Reimbursement Guide - LEARN MORE

Nerve Block Needle

Epimed’s nerve block needles are developed for site specific pain relief and help provide several clinical benefits for the best potential outcomes.

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This application is for facilities and practices located in the United States only. For all other countries, please Contact Sales.

This form is for United States applicants only. Non-US applicants should contact sales to learn more. Approvals can take up to 5 business days and additional information may be requested.

Clinic/Hospital Name*

Billing Address*

City*

State*

Zip*

Country*

Email for Invoices*

Buying Affliation*

Examples: HCA, Novation, etc.

Federal ID*

Tax Exempt*

Is the facility exempt from paying sales tax?*

Yes

Upload Tax Exempt Certificate*

Accepted file types: pdf, png, jpg, Max. file size: 1 MB.

IHR-530 Rev. 12

Please provide a primary shipping address.

Shipping Address*

City*

State*

Zip*

County*

Country*

Telephone*

Fax

IHR-530 Rev. 12

Primary A/P Contact*

Phone*

Email*

Add more contacts?*

Yes

Please select:

Purchasing Agent

Materials Manager

Nurse

Risk Manager

Other Contact

Purchasing Agent

Phone

Materials Mgt

Phone

Nurse

Phone

Risk Manager

Phone

Other

Phone

IHR-530 Rev. 12

Physician Office*

City*

State*

Postal Code*

Country*

Email*

Telephone*

Fax

IHR-530 Rev. 12

Physician First Name*

Physician Last Name*

Degree*

Pain Practice Specialty*

IHR-530 Rev. 12

This field is for validation purposes and should be left unchanged.

Request Online Access

This form is for users that already have an Epimed account, but do not yet have online access.

Step 1 of 3

Purchasing Company Name(Required)

Purchasing Contact First Name(Required)

Purchasing Contact Last Name(Required)

PO Number for Last Order(Required)

This is for verification purposes.

Customer Number(Required)

This is located on your invoice.

Create Username(Required)

The username is permanent and cannot be changed in the future.

Create Password(Required)

You will be asked to update or change this in the future.

Display Name(Required)

This is what will display if you a leave a product review.

Contact Email(Required)

This will be used as the contact email for online access.

Consent(Required)

I have read and agree to the site's Terms of Use and Privacy Policy.

Terms of Use:
Read Terms of Use

Privacy Policy:
Read Privacy Policy

Name

This field is for validation purposes and should be left unchanged.

Cryo Painblocker™: Setting a New Standard in Cryoneuroablation - EXPLORE

2022 Reimbursement Guide - LEARN MORE

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Request Online Access