OrthoHeal Prospective Distributor Form-Phase III
First Name *
Middle Name
Last Name *
Email Address *
We will keep you updated about OrthoHeal and FlexiOH through emails..!!!
Contact number *
Don't worry !!! We will keep it private and use only when urgent action required.
Website *
Base Location *
Company Name *
Business Type *
This will help us to maintain your data in our system for further recognition and communication.
Office area and Godown area. (in Sq. feet) *
Area under operation. (in Sq. feet) *
Current Distributor *
If yes, please mention company names. *
It is required for us to understand your current clientele profile.
Current Turnover (in INR) *
Experience (in years) *
Current Employee Strength *
Required to understand your management and sales team strength.
Any Current/ Previous Business in Medical Device. *
Do you deal with the consumable products? *
GST No. *
Drug License Number
Brief Profile *
Short description on company profile and expertise area.
Total number of Orthopedic hospitals in your network *
Please provide information in figures about total orthopedic hospital reach by your organization
Enlist Coverage Areas *
Select the reason for distributorship *
Draw out your marketing plan for OrthoHeal product (FlexiOH). *
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