BRIJ Medical

Main Contact First Name

Main Contact Last Name

Main Contact Title

Phone number

🇺🇸

Surgeon’s First Name

Surgeon’s Last Name

Practice Name

Surgeon/User Specialty

NPI Number

Will you be requesting to set up a trial or evaluation for one location or multiple locations?

Is there a Surgeon requesting to use Brijjit devices?

How did you hear about us

Sales Rep Code:

Password

Address

Failed to connect to the Google Maps API.If you are the site owner, make sure that the Maps JavaScript and Places APIs are scoped correctly, and that "shop.brijmedical.com" is permitted within your key’s restricted referrers.

Apartment, suite, etc. (optional)

Country

City

Zip/Postal code

Main Contact First Name

Main Contact Last Name

Main Contact Title

Email address

Confirm Email

Phone number

🇺🇸

Facility Name

Address

Apartment, suite, etc. (optional)

Country

City

Zip/Postal code

Health System Affiliation (if applicable)

NPI Number

Will you be requesting to set up a trial or evaluation for one location or multiple locations?

Is there a Surgeon requesting to use Brijjit devices?

Surgeon’s First Name

Surgeon’s Last Name

Surgeon/User Specialty

Surgeon's Email

Surgeon's Phone

Password

Password confirmation

How did you hear about us?

Sales Rep Code:

First name

Last name

Phone number

🇺🇸

Email address

Do you have a surgery scheduled?

Your Surgeon’s First Name

Your Surgeon’s Last Name

Your Surgeon’s Phone number

🇺🇸

Surgeon Specialty

Please tell us more about your request to use/ purchase Brijjit

Thank you for your interest in BRIJ Medical! Let's get started!