New Client Questionnaire

Required for all new clients. Submit this form so we can generate a sterilization services agreement and begin your project intake.

Questions Required for Our Services Agreement

Full Company Name

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Contact

First Name

Last Name

Contact Phone

Contact Email

Alternate Contact

First Name

Last Name

Alternate Phone

Alternate Email

Billing & Legal

Accounts Payable Email

State of Incorporation

Can your devices stay in the sterilizer at the specified exposure temperature over the weekend?

Yes

This helps decrease turnaround times for non-validated processes. If Andersen has or intends to validate your sterilization process, select No. Validated devices cannot be left in the sterilizer longer than permitted.

Cycle Preference

Standard cycle (50°C)

Low-temperature cycle (35°C)

Acknowledge that you are responsible for properly packaging and labeling the devices for sterilization

Yes

Acknowledge that you are not labeling and/or marketing the devices as sterile

Acknowledged (devices are not labeled sterile)

N/A (Devices are labeled sterile and Andersen will validate the process)

Only validated devices can be labeled with a sterile label claim. If Andersen has or will validate the sterilization process, select N/A.

Additional Information

If you are human, leave this field blank.

Having trouble with the form? Contact us directly at [email protected] or call (919) 388-5844.