Beckman Coulter, Inc.

For more information or to place an order for the Hemoccult brand limited time promotion, Buy 3, Get 1 Free,** complete the short form below and click send at the bottom of the page.

If you have any questions, please contact Beckman Coulter Technical Marketing at 1-800-877-6242 or email us at askpcd@beckman.com.

Tell Us About Yourself:

*Indicates required fields.

First Name*
Last Name*
Title
Institution*
Address Line 1*
Address Line 2
City
State	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming
Zip/Postal Code*
Country
Phone*
Fax
Email Address*
Distributor

Where did you hear about Hemoccult brand?*
What FOBT are you currently using?*
What Type of Information are You Interested In?
Are you interested in getting a hard copy of the CRC screening resources and patient compliance package tools? (check all that apply)	Colorectal Cancer Facts Poster Hemoccult II/Hemoccult SENSA Patient Checklist Hemoccult ICT Patient Checklist Hemoccult ICT Test Procedure Patient Reminder Post Card
Are you interested in key clinical studies providing effectiveness of Hemoccult products?	Yes	No
Are you interested in patient education material? (check all that apply)	Special Promotion Details CRC Information Data Sheets Videos Patient Test Instructions
Are you interested in CRC screening program information and/or help?	Yes	No

**For new customers only, receive a 25% discount when you purchase three or more cases of Hemoccult or Hemoccult SENSA guaiac tests, or receive a free box of Hemoccult ICT collection cards with every box purchased. Hemoccult ICT Test Device, part number 395067, is excluded from this promotion.

Beckman Coulter, the stylized logo, and Hemoccult are registered trademarks of Beckman Coulter, Inc.