Biomet® Link™ Clinic Lead Submission
(To be completed by a Biomet Sales Representative)

Complete the form below, then click the Submit button. A Biomet® Link™ team member will review your request and contact you shortly.

*Required

Sales Representative Information
First/Last Name*
Phone Number*
Email Address*
PTM/IA*
RVP*
Has your PTM/IA been contacted regarding this account? Yes No
Has your RVP been contacted regarding this lead? Yes No
Practice Information
Practice Name*
Address*

City*
State*
Zip*
Contact's Name*
Contact's Title*
Contact's Direct Phone
Contact's Email
Practice Demographics
How many Doctors are in the practice?*
How many locations?*
What are the primary specialties of the physicians in the practice? Foot/Ankle General Hand/Wrist Knee Shoulder/Elbow Spine Total Joints
*Which of the following best describes what the practice does in regards to the processing of braces/supports? (choose one)** Refer all braces and support fittings to an external provider via prescription Use a Biomet Stock and Bill Use a competitive Stock and Bill Purchase braces and bill using a third party billing service Purchase braces and bill using in-house staff
How are the practice's high end braces handled? (choose one) In-House Referred Outside
Additional questions or comments