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Fetal Badges
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The clinic will be charged for the additional badge on a pro-rated basis.
*
denotes required fields
Dealer Account Number
*
Clinic Name
*
Primary Contact
*
Clinic Phone Number
*
E-Mail
*
Start Date For Fetal Badge:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2025
2026
2027
*
End Date For Fetal Badge:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2025
2026
2027
2028
*
Frequency of Service :
Quarterly
Monthly
Request a Fetal Badge for the Following Employee:
*
Employee Name
*
SS/Employee ID
*
DOB (XX/XX/XXXX)
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