Custom Bag Questionnaire

The following information would be used to prepare a quotation for your review:

Your Name

Your Title

Company Name

Your Email

Mailing Address

City

State/Province

Postal Code

Country

Phone

Fax

Bag Size & Description:

Anticipated Product Use:
Blood handlingDrainageFluid administrationWasteLong-term storageOther:

Potential Quantities:
First order:
Per month:
Per year:

Packaging Requirements:
Bulk-packIndividualOther:

Material Description:
Thickness:

Class Vl medical grade: YesNo

Vendor name:

Vendor material number:

Type of material:
PVCEVAEVAOther:

Porting Specifications:
Total number of ports required:
Port: OD: ID: Length: Placement:
Port: OD: ID: Length: Placement:
Port: OD: ID: Length: Placement:

Other port data:

Vent required: YesNo
Placement:

Other features required:

Date quotation required:

Additional Message