Sales Date* Date Format: MM slash DD slash YYYY Salesperson* First Last How did the customer hear about Dymedix?*Sales RepresentativeTradeshowMagazine AdInternetDistributerCustomer ReferralOtherContact Name* First Last Email* Position*Facility Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Amplifier*PSG CADWELLPSG SLEEP VIRTUALPSG GRASSPSG NICOLETPSG NIHON KOHDENPSG REMBRANDTPSG SANDMANPSG SENSORMEDICS / CAREFUSIONPSG STELLATEPSG XLTECHPSG NATUSPSG EMBLA S4500PSG EMBLA N7000 BEDSIDE UNITPSG EMBLA N7000 PATIENT UNITPSG COMPUMEDICS E-SERIESPSG COMPUMEDICS GRAELPSG ALICE 5PSG ALICE 6HST NOMADHST NOX – T3Product CategoryAirflow SensorsFiltration ModulesEffort Belt Kits ReusableEffort Belt Kits DisposableSurface ElectrodesEffort Belt Kits Semi-DisposableProducts*Select Product10-14000-0201 TriplePlay, Reusable Sensor, Infant10-14000-0301 TriplePlay, Reusable Sensor, Pediatric -10-14000-0401 TriplePlay, Reusable Sensor, Small -10-14000-0501 TriplePlay, Reusable Sensor, Medium -10-10000-0001 Airflow Sensor, Disposable, Neonatal10-10000-0201 Airflow Sensor, Disposable, Infant -10-10000-0301 Airflow Sensor, Disposable, Pediatric -10-10000-0401 Airflow Sensor, Disposable, Small10-10000-0501 Airflow Sensor, Disposable, Medium10-10000-0601 Airflow Sensor, Disposable, Large10-21001-0601 Snore Sensor, Disposable, Large12-20004-0001 Reusable Interface Cable, Keyhole12-20001-0001 Reusable Interface Cable, Snore10-15000-0601 Snore Sensor, ReusableProducts*Select Product12-10120-0001 FM1 - PSG (Systems other than Listed Below)12-10016-0001 FM1 - Embla12-10003-0001 FM1 - Alice 512-10017-0001 FM1 - Alice 612-10018-0001 FM1 - Grael12-40200-0001 FM2 - Universal (PSG Systems other than Listed Below) 1.5mm12-40201-0001 FM2 - Embla12-40204-0001 FM2 - Alice 5 -12-40208-0001 FM2 - Alice 6 -12-40209-0001 FM2 - Grael -12-40202-0001 FM3 - Universal (PSG Systems other than Listed Below) 1.5mm12-40203-0001 FM3 - Embla12-40205-0001 FM3 - Alice 512-40206-0001FM3 - Alice 612-40207-0001 FM3 - Grael12-40300-0001 FM4 - Universal (PSG Systems other than Listed Below) 1.5mm12-40301-0001 FM4 - Embla12-40302-0001 FM4 - Alice 512-40304-0001 FM4 - Grael12-40305-0001 FM4 - Embla Bedside Unit12-40306-0001 FM4 - Embla with Patient Unit12-40310-0001 FM5 - Universal (PSG Systems other than Listed Below) 1.5mm12-40311-0001FM5 - Embla12-40312-0001 FM5 - Alice 512-40314-0001 FM5 - Grael12-40315-0001 FM5 - Embla Bedside Unit12-40316-0001 FM5 - Embla with Patient Unit12-40320-0001 iFM - Universal (PSG Systems other than Listed Below) 1.5mm12-40321-0001 iFM - Embla12-40322-0001 iFM - Alice 512-40323-0001 iFM - Alice 6Products*Select Product12-41113-0001 Perfect Fit SUM Module with cable - Adult18-14201-0602 Perfect Fit™SUM Adult Effort Belt Kit: 2 sensors, 2 straps (45"), Sum Interface Cable12-41113-0301 Perfect Fit™ SUM Module with cable - Pediatric18-12201-0302 Perfect Fit™Pediatric Effort Belt Kit: 2 sensors, 2 ea-15",25",35" Straps, Sum Interface Cable18-14210-0602 Perfect Fit™ II Adult Effort Belt Kit: 2 Sensors, 2-ea 45" & 60" Straps18-14211-0602 Perfect Fit ™II Adult Effort Belt Kit: 2 Sensors, 2-ea 45" & 60" Straps, Alice® 518-12210-0302 Perfect Fit™ II Pediatric Effort Belt Kit: 2 Sensors, 2-ea 15", 25", 35" straps18-12211-0302 Perfect Fit™ II Pediatric Effort Belt Kit: 2 Sensors, 2-ea 15", 25", 35" straps, Alice® 518-14213-0602 Perfect Fit™ II R/S Adult Kit includes: 2- Perfect Fit™ II R/S sensors, 2-45” Effort Belt Straps, 2-60” Effort Belt Straps, and 2- R/S Interface Cables, Embla18-14214-0602 Perfect Fit™ II R/S Adult Kit includes: 2- Perfect Fit™ II R/S sensors, 2-45” Effort Belt Straps, 2-60” Effort Belt Straps, and 2- R/S Interface Cables, Embla, 1.5 mm18-14215-0602 Perfect Fit™ II R/S Adult Kit includes: 2- Perfect Fit™ II R/S sensors, 2-45” Effort Belt Straps, 2-60” Effort Belt Straps, and 2- R/S Interface Cables, Grael18-14216-0602 Perfect Fit™ II R/S Adult Kit includes: 2- Perfect Fit™ II R/S sensors, 2-45” Effort Belt Straps, 2-60” Effort Belt Straps, and 2- R/S Interface Cables, Alice 618-12213-0302 Perfect Fit™ II R/S Pediatric Kit includes: 2- Perfect Fit™II R/S sensors, 2-15” Effort Belt Strap, 2-25” Effort Belt Strap, and 2-35” Effort Belt Strap and 2- R/S Interface Cable, Embla18-12214-0302 Perfect Fit™ II R/S Pediatric Kit includes: 2- Perfect Fit™II R/S sensors, 2-15” Effort Belt Strap, 2-25” Effort Belt Strap, and 2-35” Effort Belt Strap and 2- R/S Interface Cable, Embla, 1.5 mm18-12215-0302 Perfect Fit™ II R/S Pediatric Kit includes: 2- Perfect Fit™II R/S sensors, 2-15” Effort Belt Strap, 2-25” Effort Belt Strap, and 2-35” Effort Belt Strap and 2- R/S Interface Cable, Grael18-12216-0302 Perfect Fit™ II R/S Pediatric Kit includes: 2- Perfect Fit™II R/S sensors, 2-15” Effort Belt Strap, 2-25” Effort Belt Strap, and 2-35” Effort Belt Strap and 2- R/S Interface Cable, Alice 6Products*Select ProductFT - PED Universal FastTrack Starter Kit, Pediatric, UniversalFT - Universal FastTrack Starter Kit, Adult, UniversalFT - PED Alice 5 FastTrack Starter Kit, Pediatric, Alice 5FT - Alice 5 FastTrack Starter Kit, Adult, Alice 5FT - PED Embla FastTrack Starter Kit, Pediatric, EmblaFT- Embla FastTrack Starter Kit, Adult, EmblaFT- PED Grael FastTrack Starter Kit, Pediatric, GraelFT - Grael FastTrack Starter Kit, Adult, GraelFT - PED Alice 6 FastTrack Starter Kit, Pediatric, Alice 6FT - Alice 6 FastTrack Starter Kit, Adult, Alice 6Products*Select ProductPF3D - Universal Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3-D sensors, 5-50 yard rolls of Effort Belt Strap, 1.5 mmPF3D - Alice 5 Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, Alice 5PF3D - Embla Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, EmblaPF3D - Embla N7000 Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, Embla N7000PF3D - Alice 6 Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, Alice 6PF3D - Grael Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, GraelPF3D - NOX-T3 Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, NOX-T3PF3D - NOMAD Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, NOMADPF3D - SUM Adult Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, SUM AdultPF3D - SUM Ped Perfect Fit 3D REUSABLE-Disposable Kit includes: 2- Perfect Fit™3D sensors, 5-50 yard rolls of Effort Belt Strap, SUM , PediatricSF1 – Lullaby Sampler Universal KitSF2 - Lullaby Sampler Alice 5 KitSF3 - Lullaby Sampler Alice 6 KitSF4 - Lullaby Sampler Embla KitSF5 - Lullaby Sampler Grael KitPF3D-1 - Perfect Fit™ 3D Effort Belt Sensor, Abdomen, 1.5 mmPF3D-2 - Perfect Fit™ 3D Effort Belt Sensor, Abdomen, Alice 5PF3D-3 - Perfect Fit™ 3D Effort Belt Sensor, Abdomen, EmblaPF3D-4 - Perfect Fit 3D Effort Belt Sensor, Abdomen, Embla N7000PF3D-5 - Perfect Fit 3D Effort Belt Sensor, Abdomen, Alice 6PF3D-6 - Perfect Fit 3D Effort Belt Sensor, Abdomen, GraelFastTrack Sample Pack UniversalFastTrack Sample Pack AliceFastTrack Sample Pack EmblaFastTrack Sample Pack GraelProducts*Select Product13-30000-0001 Chin Electrode Patch13-40000-0001 Dual EMG Electrode13-41000-0001 Wired Dual EMG Electrode, 120 in13-41001-0001 Wired Dual EMG Electrode, 60 in13-14000-4802 Dual Snap Lead Wire, 48", 2 Pack13-14000-6002 Dual Snap Lead Wire, 60", 2 Pack13-14000-1002 Dual Snap Lead Wire, 100", 2 Pack13-14000-1202 Dual Snap Lead Wire, 120", 2 Pack13-10100-4010 Disposable Gold 9mm Cup EEG Electrode, 40" (1m), 10pack13-10100-6010 Disposable Gold 9mm Cup EEG Electrode, 60" (1.5m), 10pack13-10100-8010 Disposable Gold 9mm Cup EEG Electrode, 80" (2m), 10pack13-10100-1010 Disposable Gold 9mm Cup EEG Electrode, 100" (2.5m), 10pack13-31000-0001 Pediatric Triple Chin EMG Patch12-10180-0001 XM Extremity Movement Interface Cable13-50000-0001 XM Extremity Movement SensorQuantitySelect Quantity12345Add ProductOrder Total*Clear ProductsComments/NotesEmailThis field is for validation purposes and should be left unchanged.