Please provide the following contact information: * Are Required Fields. Name * Title Organization Country Address * Work Phone (area code) * City * FAX (area code) State * E-mail * Zip Code * Website What type of cable/equipment are you looking for? Please Select One ECG Interconnect Cable ECG and IBP Interconnect Cables Bifurcated Cables Output Adapters Input Adapters Patient Cables Patient Cable to Electrode Adapters Extension Cables Alarm Cables for Monitors and Respirators IBP Adapters and Cables Batteries Chart Paper Other Which device is the patient connected to? Please Select One Monitor Defibrillator Balloon Pump Other Manufacturer: Model Name: Model Number: What kind of connector is on this end of the cable? Please Select One 1/4" 3Ckt Phone Plug 1/4" 2Ckt Phone Plug 16 Pin Output 4 PIN DIN 4 PIN LEMO 7 PIN Mini DIN 1/8" MINI Plug TT253 - Mil. Spec. Phone Plug 6 PIN LEMO Output 15 PIN Sub D Systems Connector Other What level of signal is intended to be inserted at this end? Please Select One 1 VOLT ECG 1 VOLT ECG & 1 VOLT IBP Other Where does the other end of the cable connect to? Manufacturer: Model Name: Model Number: What kind of connector is on this end of the cable? Please Select One AAMI 6 PIN AAMI 6 PIN Lead II 8 PIN Patient Input 10 PIN 11 PIN Patient Input 12 PIN HP 17 PIN ECG 1/4 " 2CKT Phone 1/4" 3CKT Phone 5 PIN DIN 12 PIN Physio-control Lifepak ECG Other What level of signal is intended to be delivered at this end? Please Select One 1 VOLT ECG 1 Volt IBP 1 Mv Patient Input Lead II Only 5 Wire 1MV Patient Input 3 Wire 1MV Patient Input Sync Pulse Input Other Length of cable needed: 14 feet - Standard 10 feet 20 feet other Where is this cable being used: Please Select One O.R. ICU/CCU Crash Cart EP/CATH Lab Other What is the cable being used for: Please Select One Cardioversion Remote Monitoring Other Additional Comments: PRINT FORM