Dear PMI Customer:

Before Progressive Medical International can ship FDA rated prescription drugs and devices to you (such as ET tubes, Nasal Cannulas, Non-Rebreather Masks, LMA's, I.V. catheters, needles, sets, I.V. solutions, etc...) we must gain authorization from your medical Director or obtain your state license number. To comply with these FDA regulations we request that you fill out the following information and email it back to us.
   
Company Name  
PMI Customer Number  
First Name   
Last Name  
Address  
   
City  
State  
Zip  
E-Mail Address  
Phone  
Fax  
 
MEDICAL DIRECTOR AUTHORIZATION (OR AUTHORIZING PHYSICIAN)
Agency Name  
is hereby authorized to purchase restricted medical products from Progressive Medical International by the authority of
Physician's Name
Medical Director /Physician License Number  
License Expiration Date  
 
STATE LICENSE
If your company is licensed to purchase FDA rated drugs and devices, but does not have a Medical Director or authorizing physician, please complete the following information:
State License Number  
State License Expiration Date