Request

Request form

Complete this form.

Company Name*
Your Name*
E-mail Address*
E-mail Address(Retype)*
Zip Code	( ex：999-9999 )
Country
Address1*
Address2
Telephone*	( ex：03-9999-9999 )
Fax	( ex：03-9999-9999 )
Mobile phone
Code	19662
Name	Video Gastroscope
Brand	FUJIFILM
Model	EG-580NW2
Endorsement number
Status	Under Nego
Price
Comment	EG-580NW2 Gastrscope
Specification & Options	Insertion tube 5.9mm Channel size 2.4mm *Working length 1100mm
Configuration
Condition	Tested / Patient ready
inquiry*	(1000characters)